Confidential Rx / Medical Question Submission 

  This form should be used when:
  • You would like a confidential answer to your medical or drug-related question.
  • ...or you would like your query researched and reviewed by our team of pharmacists.
  • ...or you've got a tough question that no one else can satisfactorily answer.
  How this works:
  • Fill out the form below and click the "Submit" button at the bottom of the screen.  The fee for this service starts at $25.  Actual charges will vary depending on the nature of your question and the research required for the response.
  • You will be notified by email how long it will take to research and provide the answer to your question.  At that time we may ask you for additional information.
  • The total fee will be quoted to you.  At that point you may accept or decline.  You are under no obligation until you agree to proceed.
  • Finally, your answer will be emailed or faxed to you depending on your preference.

If for some reason we are unable to answer your question or if we are unable to answer your question within the quoted time frame you will be issued a complete refund.


Your privacy and the security of the transmitted information is important to us.  No personal information submitted through this form will be disclosed to anyone other than our team of pharmacists who will be processing your request.  Payment data will only be transmitted through our payment processor for ultimate payment through issuing banks.  No information is stored on our server.

Patient medical background information:

 * Indicates required fields.  Other fields are optional 

*Patient Name

*email address


*Approximate Weight

*Male or Female?


Yes      No

*Alcohol Use

*Prescription and non-Rx medications

(Indicate "none" if necessary.  Separate multiple entries with commas.)

*Medication Allergies

(Indicate "none" if necessary.  Separate multiple entries with commas.)

*Medical Conditions or Chronic Diseases

(Indicate "none" if necessary.  Separate multiple entries with commas.)

Payment Information:

*Card Type
*Card Number
*Card Expiration
*Billing Street Address

*Billing City, State, Zip Code

*Daytime Phone number

Your Question:

Please ask your question here.  The more details you can provide the better.

Disclaimer:  The information provided by our team of pharmacists is not intended as a substitute for your physician's help, diagnosis, or treatment but is to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem,  medical condition, or to discuss any information that we may provide to you as a result of responding to your question.