Prescription Request Form Prescription Request Form Title Mr Mrs MS Legal Name Middle Last Email Phone How did you hear about us Address 1 Address 2 City State --- Select ---- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP Date of Birth Gender Male Female Please pick which medications you would like to be prescribed to you. One of our office staff will call you in the next 1-2 business day to go over your order with you and schedule an appointment with one of our Providers. Duration (You can select multiple) 1 dose 1 month 3 months 6 months 12 months Drugs (You can select multiple) Ivermectin 12mg Capsule (compounded) Ivermectin 15mg Capsule (compounded) Ivermectin 18mg Capsule (compounded) Ivermectin 21mg Capsule (compounded) Ivermectin 24mg Capsule (compounded) Ivermectin 3mg tablet, #20 Ivermectin 12mg Troche/Lozenge Azithromycin 250mg (Z Pack) each (6 tablets) Azithromycin 500mg Tablet, #10 Doxycycline 100mg Capsule, #20 Levofloxacin 500mg Tablet, #20 Hydroxychloroquine 200mg Tablets, #30 or 60 Methylene Blue 5mg Capsule (compounded) 60 or 100 Methylene Blue 10mg Capsule (compounded) 60 or 100 Methylene Blue 1mg/ml Oral Solution 250ml Oral PDT Device Budesonide 0.5mg/2ml, (#60 Ampules for Inhalation) Ipratropium 0.02% Nebulizer Vials, (#60 Ampules for Inhalation) Levalbuterol 1.25mg/3ml Nebulizer (#30 Ampules for Inhalation) Albuterol 0.083% Nebulizer Vials, (#60 Ampules for Inhalation) Albuterol/Ipratropium (Duo-Neb) (#60 Ampules for Inhalation) Nebulizer Device (with Mask and tubing) Pulse Oximeter Device Colchicine 0.6mg Tablets/each Medrol Dosepack - 4mg 21UU DosePack #7 Dexamethazone 4mg Tablets, #20 Nattokinase Monthly Vitamin Kit Pepcid (30 ct) Kefle 500mg (10 ct) 8/MB Bundle (M6ethylene Blue 1mg/ml Oral Solution 250ml, Oral PDT Device) Azithromycin 500mg Tablet, #10 Budesonide 0.5mg/2ml, (#60 Ampules for Inhalation) Ipratropium 0.02% Nebulizer Vials, (#60 Ampules for Inhalation) Pulse Oximeter Device Nebulizer Device with Mask and tubing ) Submit
