Step Request for Acyclovir 5% Cream + Hydrocortisone 2.5% with Aloe Vera 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:

Email Address: EvePhone:

Address: City: State: Zip:

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

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. cold sores):

How long have you had your symptoms?


Where do lesions occur? (e.g. on outside of lips):

Note: We will only approve this medication for treatment of oral herpes (cold sores) on the lips.

What part of the body will you be using the Cream?


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

list what you will use.  If not, please write "none".

Patients approved for a prescription for Zovirax 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.  By clicking the continue button below I state that I have answered all questions truthfully to the best of my knowledge and ability.

This is a secure page

If you would prefer to pay by check please follow the directions below:

Your prescription, if approved, will be filled by our pharmacist. You will not be charged and your check or money order will be returned if it is determined by the pharmacist that your application should not be approved. Mail this page with your payment ($39.99 Rx + $5 professional fee + SHIPPING & HANDLING choice) check or money order payable to WebRx Pharmacy Palace to:


6583 Gateway Ave

Sarasota, FL 34231

Click here for shipping rates and details.

If you would prefer to fax the information please print, click reset, and fax it to (941)296-7447 then click here to make payment.

Privacy Statement:  No information is collected until the button above 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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