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.

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NOTE FOR SPEEDY CHECKOUT:  This method will not verify your card number or provide approval/denial information so enter your card number very carefully. An email receipt will be sent to you later with final approval.  Also, your shipping & billing address must be the same.  For speedy checkout, fill out the information below, then click the submit or continue button above.  Once you arrive at STEP 2, do not proceed and close your window.

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WHEN FAXING:  Please fill in the information here, print the page, then fax it to (941) 296-7447 - NO NEED TO CLICK SUBMIT ABOVE IF FAXING or MAILING..

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Mailing address:

6583 Gateway Ave

Sarasota, FL 34231

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