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Hydroxychloroquine Prescription Request
PHYSICIAN REVIEW - ORDER NOW
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Patient Full Name
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Patient Email Address
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Sex
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Female
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Date of Birth
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Phone Number
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Address
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City, State, ZIP
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Past Medical Problems (e.g. Asthma - if none, type "none")
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Current Medications (if none, type "none")
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Known Allergies (if none, type "none")
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Are you pregnant?
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Are you breastfeeding?
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Why are you requesting this medicine? (please provide extensive detail)
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Has the patient ever had an allergic reaction to chloroquine (Aralen), hydroxychloroquine (Plaquenil) or another 4-aminoquinoline compound?
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Yes
No
Has the patient ever been diagnosed with heart failure or cardiomyopathy?
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Yes
No
Has the patient ever been diagnosed with a low heart rate, cardiac arrhythmia or a long QT interval?
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Yes
No
Has the patient ever been diagnosed with low potassium, low magnesium, or low blood glucose levels?
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Yes
No
Has the patient been diagnosed with an eye problem or hearing problem?
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Has the patient been diagnosed with severe psoriasis, porphyria, or glucose-6-phosphate dehydrogenase (G-6-PD) deficiency?
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Has the patient previously had a seizure?
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Yes
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Has the patient been diagnosed with a blood disorder such as low white or red blood cell counts, agranulocytosis or aplastic anemia?
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Is the patient currently taking cimetidine, digoxin, insulin, amiodarone, moxifloxacin, cyclosporine, mefloquine, or tamoxifen?
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Yes
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I understand that this medicine is made by Zydus Healthcare, a leading manufacturer in India and this medicine will be shipped directly from India. I also accept that shipping times will take an average of 4 weeks with the present coronovirus delays.
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Yes I understand
No thank you, I am not interested
I hereby request
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Hydroxychloroquine 200mg x 60 tabs @ $99 (-10% discount) + $20 doctor fee = $109 USD
Hydroxychloroquine 200mg x 120 tabs @ $175 (-10% discount) + $20 doctor fee = $177.50 USD
Hydroxychloroquine 200mg x 180 tabs @ $235 (-10% discount) + $20 doctor fee = $231.50 USD
Hydroxychloroquine 200mg x 240 tabs @ $309 (-10% discount) + $20 doctor fee = $299.00 USD
Hydroxychloroquine 200mg x 450 tabs @ $535 (-10% discount) + $20 doctor fee = $499.00 USD
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Credit Card (Visa/MC), exp. date, CV#
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How did you hear about us ?
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I hereby confirm that all questions were answered accurately and I hold harmless all medical providers approving or not approving a prescription. I have approached the medical provider myself requesting a specific medication for the purpose listed. I will not take the medicine itself unless I am advised by a local physician directly. I also hold harmless the pharmacy and website platform by which I found this medicine and am completing this order. I take full personal responsibility for my decision to purchase this medicine.
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