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: Alberta British Columbia Iqaluit Manitoba New Brunswick Newfoundland & Labrador New South Wales Northern Australia Nova Scotia NW Territory Nunavut Ontario Prince Edward Island Quebec Queensland Saskatchewan South Australia Tasmania Victoria Western Australia Yucon Other Non-USA clients:  Country selection is located on the payment & shipping page.

Notice:  Within the USA, this product can only be shipped to Florida residents.

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:

RxPalace.com

 6583 Gateway Ave

Sarasota, FL  34231

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