Step Request for Denavir Prescription:

This information is necessary in order to process your request for your prescription. Please answer all questions

completely and truthfully.  All fields are required.  Patients are advised that if after using the medication and

symptoms do not improve to seek medical advice from a physician.

Last Name: First: Middle: DayPhone:

Email Address: (i.e. bob@aol.com) EvePhone:

Address: City: State:  Zip:

Notice:  Within the USA, this product can only be shipped to Florida residents.

Male Female Date of Birth: Are you pregnant or nursing a baby?

Current Medications: 

Medication Allergies:

Medical Conditions or Chronic Diseases:

Chief Current Complaint (e.g. Cold Sores):

Location of sores: (e.g. on lips, inside mouth, face)

What part of body will you be using Denavir?

How long have you had this condition?

How often do symptoms occur?

What other remedies have you tried?

Please review your information & make any changes before submitting the form.

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