Step Request for generic Benzamycin 23.3gm 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: Evening Phone:

Address:City:State/Province:Zip:

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

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:

Chief Current Complaint (e.g. acne):

How long have you had this condition? 

Blemishes are located on what part(s) of the body?

What area(s) will you be using this product?

What else are you using to treat acne? 

How did you hear about this website? 

If you have a discount or rebate code please enter it here: OPTIONAL

Enter the name of the referrer here: OPTIONAL

Patients approved for a prescription for this medication are hereby advised that this product should not be used near deep or puncture wounds.

Please review your information & make any changes before submitting the form.

  This is a secure page

To fax the information please print then fax to (941) 296-7447 then click here to make payment.

Privacy Statement:  Read our complete privacy policy here.

Click here to return to WebRx Pharmacy Palace or click here to return to the products page.