Step Request for generic Domeboro® Otic Prescription:

This information is necessary in order to process your request for your prescription. Please answer all questions completely and truthfully.  All fields required.  Patients are advised that if after using the medication & symptoms don't improve to seek medical advice from a physician.

 

Last Name:First:Middle:DayPhone:

Email Address: Evening Phone:

Address:City:State: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. swim ear prevention):

How long have you had this condition? 

What else are you using to for this purpose? 

How did you hear about this website? 

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

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