JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Chloroquine Pharmacist Review @
insulinhub.com
Chloroquine Phosphate 250mg plus zinc sulfate tabs
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Please confirm you are looking for chloroquine rather than hydroxychloroquine
*
Chloroquine - proceed with this form
Hydroxychloroquine - PLEASE GO TO
https://forms.gle/4LycqZbuZVhGoxWM8
Required
Patient Name
*
Your answer
Patient Email Address
*
Your answer
Sex
*
Male
Female
Birth Date
*
Your answer
Phone Number
*
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Past Medicial Problems (e.g. Asthma - if none, type "none")
*
Your answer
Current Medications (if none, type "none")
*
Your answer
Known Allergies (if none, type "none")
*
Your answer
Are you pregnant?
*
Yes
No
Are you breastfeeding?
*
Yes
No
Medication Desired?
*
Chloroquine 250mg plus Zinc Sulfate tablets
Nothing at this time
Has the patient ever had an allergic reaction to chloroquine (Aralen), hydroxychloroquine (Plaquenil) or another 4-aminoquinoline compound?
*
Yes
No
Has the patient ever been diagnosed with heart failure or cardiomyopathy?
*
Yes
No
Has the patient ever been diagnosed with a low heart rate, cardiac arrhythmia or a long QT interval?
*
Yes
No
Has the patient ever been diagnosed with low potassium, low magnesium, or low blood glucose levels?
*
Yes
No
Has the patient been diagnosed with an eye problem or hearing problem?
*
Yes
No
Has the patient been diagnosed with severe psoriasis or glucose-6-phosphate dehydrogenase (G-6-PD) deficiency?
*
Yes
No
Has the patient previously had a seizure?
*
Yes
No
Is the patient currently taking cimetidine, insulin, amiodarone, moxifloxacin, cyclosporine, mefloquine, or tamoxifen?
*
Yes
No
Is the patient currently having a fever, shortness of breath, headache, chest pain, abdominal pain or other symptoms?
*
Yes
No
I agree that I will take the dosage of Chloroquine recommended on the package unless specifically advised by my physician to modify the dose. I understand that Chloroquine is a 10 week preventative treatment for Malaria.
*
Yes
No
Request for Chloroquine 250mg plus Zinc Sulfate 220mg (new price)
*
20 tablets Chloroquine + 60 capsules Zinc @ $109 -10% off = $99.00
Double order of above = $175.00
Triple order of above = $235.00
None of the above
Name as appears on credit card
Your answer
VISA or MC #, Exp date, CV (back of card)
Your answer
I hereby confirm that all questions were answered accurately and I hold harmless all medical providers approving or not approving this order. I understand that this medicine will be shipped from a licensed pharmacy in the United Kingdom and shipping times are usually 7 to 10 days however shipping delays are acceptable and common with the COVID 19 outbreak.
*
I agree
I disagree
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Infohealth.
Report Abuse
Forms
