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.


  This is a secure page

Click here & scroll down to FAX, MAIL, or for SPEEDY CHECKOUT...and/or for shipping & privacy info.

NOTE FOR SPEEDY CHECKOUT:  This method will not verify your card number or provide approval/denial information so enter your card number very carefully. An email receipt will be sent to you later with final approval.  Also, your shipping & billing address must be the same.  For speedy checkout, fill out the information below, then click the submit or continue button above.  Once you arrive at STEP 2, do not proceed and close your window.

  Card Type:

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..

Card Number:
Card Expiration:
CVV Security Code: What's This?
  Shipping Option:

Sign & Date:  x

 



Mailing address:

RxPalace.com

6583 Gateway Ave

Sarasota, FL 34231

Shipping & Handling Options: 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.

After printing, click here to close this window or click here to return to our home page