Step Request for Erythromycin Topical 2% Gel 60g 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.

 

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Notice:  We do NOT ship prescription medicines to residents of Missouri

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Current Medications: 

Medication Allergies:

Medical Conditions or Chronic Diseases:

Chief Current Complaint (e.g. acne):

How long have you had this condition? 

Blemishes are located on what part(s) of the body?

What area(s) will you be using the erythromycin? 

What else are you using to treat acne?

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Patients approved for a prescription for erythromycin topical gel are hereby advised that this product should not be used near

deep or puncture wounds.

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