Step Request for Ranitidine 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:

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Address:City:State:Zip:

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

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:

Describe your symptoms (e.g. heartburn, stomach pain, etc):

Will you be using any other medication or devices to treat your condition?  If yes, please

list what you will use.  If no, please write "none".

If you have a discount or rebate code please enter it here: OPTIONAL

Enter the name of the referrer here: OPTIONAL

Patients approved for a prescription for ranitidine are hereby advised that if symptoms do not improve while using this medication that it may

be a sign of a serious condition and should seek appropriate medical attention.

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