• 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10
  • 11
  • 12
  • 13
  • 14

zip code

sex

What is your date of birth?

bmi calculator

blood pressure

Please enter a recent blood pressure taken within 6 months. If you have not had your blood pressure taken with the last 6 months or do not know your blood pressure, please call your doctor. Another great way to get a recent blood pressure reading is to stop by your local pharmacy. Most local pharmacies including, Walgreens, provide FREE blood pressure checks for people 18 years and older. It is important we have a recent blood pressure in order to asses medical safety. You should not take this medication if you have high blood pressure. Blood pressure should be checked yearly.

ARE YOU BREAST FEEDING?

HAS IT BEEN MORE THAN 6 WEEKS SINCE YOUR DELIVERY?

DO YOU SMOKE CIGARETTES?

DO YOU SMOKE MORE THAN 15 CIGARETTES PER DAY AND OVER THE AGE OF 35?

HAVE YOU EVER BEEN DIAGNOSED OR TREATED FOR THE FOLLOWING? CHECK ALL THAT APPLY (PMH)

ARE YOU CURRENTLY TAKING MEDICATION? INCLUDE OVER THE COUNTER MEDICATIONS AND HERBAL VITAMINS AND SUPPLEMENTS

ANYTHING WE NEED TO KNOW?

DO YOU HAVE ANY ALLERGIES?

TREATMENT OPTIONS

PLEASE ENTER YOUR PREFERRED PHARMACY INFORMATION HERE

payment details

Payment Information

Total Payment Value: $25.00