Please chose Your Order —Please choose an option—Laxpro 20mg – 180 Tabs - $219Laxpro 20mg – 120 Tabs - $189Laxpro 20mg – 90 Tabs - $169Metoclopramide 10mg 90 tabs - $169Naltrexone/Bupropion 1.5/90mg - 90 Pills - $229Estradiol 0.5mg 180 pills - $189Estradiol 1mg 180 pills - $195Estradiol 2mg 180 pills - $199 Please confirm your order —Please choose an option—Laxpro 20mg – 180 Tabs - $219Laxpro 20mg – 120 Tabs - $189Laxpro 20mg – 90 Tabs - $169Metoclopramide 10mg 90 tabs - $169Naltrexone/Bupropion 1.5/90mg - 90 Pills - $229Estradiol 0.5mg 180 pills - $189Estradiol 1mg 180 pills - $195Estradiol 2mg 180 pills - $199 1. I want to pay you by: COD We only accept money order. You need pay cash to USPS postman to ask them to write money order to us. The USPS postman will tell you the payee name Personal Details Your First Name : Your Last Name : Your Email : Your Phone: Your Zip Code: Billing and Shipping Address Street Address: City: State: Country: Health Questionnaires Date of Birth: mm/dd/year Your Height: ft-in Your Weight: Lbs Gender: —Please choose an option—MaleFemale 1. I agree not to take any over-the-counter medicines without approval from my pharmacist. I AgreeI Disagree If you disagree, please explain why: 2. I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant. I AgreeI Disagree If you disagree, please explain why: 3. Please list all current medical conditions including high blood pressure. Choose "None" if none. NoneI will specify Specify all current medical conditions: 4. Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none. NoneI will specify 5. Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Choose "None" if none. NoneI will specify 6. Please list all medications that you plan to take while on this program. Choose "None" if none. NoneI will specify 7. Please list all past or present allergies including allergies to any medications. Choose "None" if none. NoneI will specify 8. Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none. NoneI will specify 9. Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. This cannot be left blank. I double checked the information and confirm all the information is correct , and I will pay you a money order when I pick up the drugs. I will never overdose the prescription. I also know the order cannot be cancelled when I click "place order now" link Δ (Visited 50 times, 1 visits today)
