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PROPECIA® REFILL PAGE

Please take a few minutes to fill in the following information as thoroughly and as accurately as possible.  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) There is no $75.00 consultation charge for refills.  Our physicians now require a complete medical history for refills.

Personal Information 

Please fill in all fields.  Failure to do so will delay your order processing. ALL must be completed to submit form

 

First Name
Middle Initial
Last name

Birth Date*(mm/dd/yy)

Address*

Apt#

City*
State / Province
 
Zip*
Country  
Phone*
E-mail*
Confirm E-mail*
Sex* Height Inches 
Weight Lbs.  

*Please verify these spaces, errors may result in significant delays.

Do you have any known drug allergies?

If yes, please list in the box provided:

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 exercise:


Are you currently taking any prescription and/or over the counter medication?

If yes, please list:

Do you have any of the following medical conditions?

 

Angina Hypotension
Arrhythmia Kidney Disease
Atherosclerosis Liver Disease
Benign Prostatic Hypertrophy Thyroid Disease
Prostatic Cancer Low Testosterone
Blood Disorders Neurological Complications
Congestive Heart Failure Psychiatric Disorders

Diabetes

 Rheumatological Complications
Endocrine Disorders Stroke
Erectile Dysfunction Valvular Heart Disease
Hypertension    

 

Medical Definitions

Do you have any of the above medical conditions?

If yes, please explain:

 

Do you have a history of any other medical condition?

If yes, please explain:

Have you had any surgeries in the past five (5) years?

If yes please explain:

Do you currently believe you are experiencing hair loss?

If yes, please explain:

Was your hair loss gradual?

If you answered yes, please explain and also include the age you started losing hair:

Was your hair loss sudden?

If you answered yes, please explain and also include the age you started losing hair:

Does male pattern hair loss run in your family?

If you answered yes, please explain:

Have you ever been treated for hair loss before?

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?

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

 

  90 - 1mg doses $249 + $18 Shipping = $267
180 - 1mg doses $425 + $18 Shipping = $443

 

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 Ordering Process

 

 


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Credit card number*
  		 CVV2: Code (Visa/Mastercard only)
What is CVV2 ?
Expiration date*
  		 
Name as it appears on card

Billing address

Billing city
Billing State
Billing Zipcode

*Please verify these spaces, errors may result in significant delays.


Please enter special instructions.

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. We are currently unable to ship to residents of Michigan.
  • 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.