Step Request for Transderm-Scop 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: Hm Phone:

Email Address:     Cel Phone:

Address: City: State: Zip:

Province: Non-USA clients:  Country selection is located on the payment & shipping page.

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

Male Female    Date of Birth:    Are you pregnant or nursing a baby?

Current Medications:  

Medication Allergies:

Medical Conditions or Chronic Diseases:

Do you have any diseases of the eye(s) such as glaucoma or eye pain? Yes   No

Do you have any diseases of the prostate or difficulty urinating?  Yes  No

Do you have an allergy to scopolamine or belladonna alkaloids?  Yes  No

 

Chief Current Complaint (e.g. travel sickness):

 

Please describe your symptoms and when they

occur: (e.g. nausea, when traveling by boat)

 

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

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

 

Patients approved for a prescription for Transderm-Scop patches are hereby advised that if eye pain develops while using this medication that it

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


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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

Privacy Statement:  No information is collected until the Continue button is clicked. All information provided is kept in strict confidence and will NOT be sold or shared with anyone unless it is directly related to the prescribing, dispensing, or shipment of your medication.

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