Step Request for Benzamycin 46.6gm Prescription (established clients):

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:Zip:

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? 

Patients approved for a prescription for benzamycin are hereby advised that this product should not be used near

deep or puncture wounds.

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