Step
Request for Erythromycin Pads 2% 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:
Evening Phone:
Address:
City:
State:
Zip:
Notice:
Within the USA, this product can
only be shipped to Florida residents.
Note to international clients:
Country selection is located on the payment & shipping page.
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.
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?
How
did you hear about this website?
Patients approved for a prescription for erythromycin topical
pads are hereby advised that this product should not be used near
deep or
puncture wounds.