Pain Pill Pharmacy Order Form

All fields must be filled out in order for your information to get to us. If successful you will be presented with a new screen that will show you the answers you gave. It will also show you the email address to send your email conformation too. If you don't see that screen but instead get a thank you, go back screen hit the back arrow on your browser. That will take you back to the order form. Double check all the fields and the last check box. When we receive your order we will contact you for a time frame to call for the card information. Existing patients have the option to use a Money Order, however there's an additional $20.00 charge. 1-281-726-4790

Required Questions

Please provide the following medical information.

First Name:

Last Name:

Street Address    City:

State                 Zip:

Email:

Phone: xxx-xxx-xxxx

Please Select Prescription:


Date of Birth:


Gender:


Height:


Weight:
Lbs.

I confirm that I am not to take any over-the-counter medicines without pharmacist approval.

I Agree   I Disagree, explained in the box below



I confirm that I am not to take this medication if I am trying to get pregnant, are pregnant or breast-feeding.

I Agree   I Disagree, explained in the box below



List all current medical conditions.

None   Explained in the box below



Relevant medical history

None   Explained in the box below



List all prescription drugs, including over-the-counter that you are currently taking. Include the length of time and frequency for each.

None   Detailed in the box below



List all allergies to any prescription drugs, past or present, including allergies to any other substances.

None   Explained in the box below



List all past surgeries. Provide details about the condition that was treated for each surgery and the results.

None   Explained in the box below



Has the prescription that you are ordering ever been prescribed to you before?

No   Yes  Date and Dr. Last Name provided below



Have you visited/consulted with a Physician within the last 3 months?

No   Yes  Date, Dr. Last Name and reason provided below



Do you consume alcohol? If so, will you be consuming alcohol while on this program?

No   Amount and frequency explained in the box below



What is the specific medical reason for ordering this medication. The physician makes their determination based on the exact nature of your medical condition and the prescription ordered. This is a required field.



Yes  No  Health Insurance

Yes  No  Ever Experienced Seizure

Yes  No  History of Liver or Kidney Disease

Yes  No  Opiate Dependent

Yes  No  Taking Antidepressant or Antianxiety

Disclaimer: By checking this box I confirm that my medical history information is honest, correct and complete. I am an adult 21 years or older. I agree to pay with a Credit or Debit Card unless I have the option to use a Money Order because I am an existing patient. I am competent to use the services offered and I have reviewed the Terms of Service and agree to them fully.

I understand once I submit my order the services of the doctors, pharmacist, administration and USPS will be called upon, therefore the pharmacy will not accept any requests for cancellations or refunds. I have double checked the information and confirm that all of the information is correct.

For a doctor to review orders the I.P. address will be recorded when you hit "Submit".