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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