CELEBREX®
MEDICAL QUESTIONAIRE
The following
medical history will assist our physician in deciding whether
Celebrex® is appropriate for your condition. All information provided
will remain secure, confidential and subject to all patient/physician
privilege laws. Please take a few minutes to fill in the following
information as thoroughly and accurately as possible. Please note
there will be a $75.00 consultation fee if the physician determines
that Celebrex® is appropriate for your condition. Remember that the
consultation fee includes three (3) additional refills over the next
twelve (12) months. There will be NO consultation fee if the physician determines
that Celebrex® is not appropriate for your condition.
Personal
Information
Please
fill in all fields. Failure to do so will delay your
order processing. ALL must be completed to submit form
Do you use tobacco products?
If yes, please quantify type of product and usage:
Do you consume alcohol?
If yes, please quantify type of product and usage:
Do you currently follow a routine exercise program?
If yes, please quantify type and amount of excercise:
Have you ever experienced an allergic-type reaction to sulfa drugs?
If yes, please explain:
Have you ever experienced asthma, hives or allergic type reactions after taking asprin or other NSAIDs(nonsteroidal anti-inflammatory drugs)? ie. Ibuprofen,naproxen
If yes, please explain:
Do you have any other known drug allergies?
If yes, please explain:
Are
you taking any of the following medications?
Are you currently taking any of the above?
If you answered yes, please list in the space provided here:
Are you currently taking any other prescription and/or over the counter medications?
If yes, please list:
Do
you have any of the following medical conditions?
Do
you have any of the above medical conditions?
If yes,
please explain:
Do
you have any of the following medical conditions specific to Celebrex?
Medical
Definitions
Do
you have any of the above medical conditions?
If yes,
please explain:
Have you ever experienced bloody or tarry/black stools?
If yes, please explain:
Have you ever had ulcers or stomach bleeding?
If yes, please explain:
Are you nursing and/or pregnant?
If yes, please explain:
Have you ever been hospitalized for heart failure or fluid in the lungs?
If yes, please explain:
How long have you had arthritis?
Please explain:
Have you had any surgeries in the past five (5) years?
If yes, please explain:
Do you have a history of any other medical condition?
If yes, please explain:
You
have completed the Medical Questionaire!
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CELEBREX®
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 Celebrex® 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 Celebrex® prescription entitles
you to your original order plus three (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.
100 mg Celebrex® Pills
200 mg Celebrex® 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).
(Please enter address if different than above), Please be
specific.
Please enter any special instructions.
How
did you hear about us?
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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. We are currently unable to ship to residents
of Michigan.
- I understand all the side effects of Celebrex®
- I do not have a current prescription for Celebrex® from
another physician
- I certify that I am allowed by law to use the credit card
I have presented
- I understand that my credit card will be billed $75.00 for
this consultation, along with my Celebrex® pill order
- 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, tarifs, 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 Onlinepills.com provides proof the order was shipped.
- I hereby certify that I have answered all questions truthfully
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