Step Request for Guaifenesin PSE 600mg/120mg 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.

First: Middle: DayPhone:

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

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

Note to international clients:  Country selection is located on the payment & shipping page.

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Current Medications: 

Medication Allergies:

Medical Conditions or Chronic Diseases:

Product will be used for (example: chest congestion, nasal congestion):

If for a recurring condition, how long have you had this condition?

How often do symptoms occur?

Have you taken this or a similar product before? 

If taken before, what dosage did you find

most effective? (example: 1 tab twice daily)

By clicking the continue button below I state that I have answered all questions truthfully to the best of my knowledge and ability.


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If you would prefer to fax the information  please print, click reset, and fax it to (941) 296-7447, then click here to continue with your payment or mail your check & form to:

WebRx Pharmacy Palace

501 N. Beneva Rd, Suite 550

Sarasota, FL 34232

 See shipping details.

 

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