Step Request for Benzamycin 40 gm 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/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? 

Rebate Code No.

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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WHEN FAXING:  Please fill in the information here, print the page, then fax it to (941) 296-7447 - NO NEED TO CLICK SUBMIT ABOVE IF FAXING or MAILING..

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Sign & Date:  x

 



Mailing address:

RxPalace.com

501 N. Beneva Rd, Suite 550

Sarasota, FL 34232

Shipping & Handling Options: $10 Standard, $28 2nd Day, $30 Express.  See details.

Make checks payable to RxPalace.com

Privacy Statement:  No information is collected until the Continue button 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.  Read our complete privacy policy here.

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