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delays.
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you have any known drug allergies?
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yes, please list in the box provided:
Do
you use tobacco products?
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no
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Do
you consume alcohol?
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If yes, please quantify type of product and usage:
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you currently follow a routine exercise program?
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If yes, please quantify type and amount of exercise:
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If
yes, please list:
Do
you have any of the following medical conditions?
Do
you have any of the above medical conditions?
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If yes, please explain:
Do
you have a history of any other medical condition?
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If yes, please explain:
Have
you had any surgeries in the past five (5) years?
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If yes please explain:
Do
you currently believe you are experiencing hair loss?
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yes, please explain:
Was
your hair loss gradual?
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If you answered yes, please explain and also include
the age you started losing hair:
Was
your hair loss sudden?
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If you answered yes, please explain and also include
the age you started losing hair:
Does
male pattern hair loss run in your family?
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If
you answered yes, please explain:
Have
you ever been treated for hair loss before?
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If you answered yes, please explain what type of treatment:
Propecia®
can effect a blood test called prostatic specific antigen
(PSA) for the screening of prostate cancer. It is very
important if you have a PSA test done, to inform your
physician that you are taking Propecia®. Specifically,
do you currently plan to have a PSA blood test for the
screening of prostatic cancer in the near future?
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No
choose
If you answered yes, please explain:
Note: There is no correlation between
taking Propecia® and prostate cancer.
You
have completed the Medical Questionnaire!
PROPECIA®
ORDER FORM
Please
take a few minutes to fill in the following
information as thoroughly and as accurately
as possible. There will be NO charges if your
PropeciaŽ prescription is not approved. Please
fill in all spaces completely. Spaces left blank
will only delay your order. If a question does
not apply to you please write in Not Applicable
(NA). A signature is required for delivery;
therefore, we are unable to ship to a P.O. Box.
Your approved PropeciaŽ prescription
entitles you to your original order plus(3)additional
refills at this time or over the next twelve(12)months.
Please check a box below to indicate your order.
You may also order refills at this time by selecting
the quantity that you desire.
PropeciaŽ
Pills
International orders are $46 to ship. If you
choose to ship your order outside the U.S.,
you are assuming all liability for any customs,
duties or tariffs. If for some unforeseen reason
your order is seized by Customs, we are unable
to refund your money. By selecting International
shipping, you are agreeing with these terms.
Note: International orders please add an additional
$28.00 to the above totals (difference between
$46.00 - $18.00).
Secure
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verify these spaces, errors may result in significant
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How
did you hear about us?
By
submitting this consultation form:
I
certify that I am 18 years of age or older
I
have read and agree to the Waiver of Liability
I am legally allowed to receive prescription medication
at my shipping address.
I
understand all the side effects of Propecia®
I do not have a current prescription for Propecia®
from another physician
I certify that I am allowed by law to use the credit
card I have presented
I understand that falsifying information in order
to obtain prescription medication is a violation
of both state and federal law
If outside the U.S. or Canada, I agree that I am
responsible for ALL import charges, tariffs, and
duties.
If outside the U.S. or Canada, my order is confiscated,
I accept full responsibility for the loss and shall
make no claim to my credit provider for non-delivery,
provided always that www.onlinepills.com provides
proof the order was shipped.
I hereby certify that I have answered all questions
truthfully
Please review all
information before submitting form so that your order
will not be delayed.
