Request for Famotidine 40mg tabs Prescription:

Last Name:First:Middle:DayPhone:

Email Address: EvePhone:

Address:City:State:Zip:

Note to international clients:  Country selection is located on the payment & shipping page.

Male Female Date of Birth: Are you pregnant or nursing a baby?

Current Medications:

Medication Allergies:

Medical Conditions or Chronic Diseases:

Describe your symptoms (e.g. heartburn, stomach pain, etc.):

Will you be using any other medication or devices to treat your symptoms?  If yes, please

list what you will use.  If no, please write "none".

After you have completed all fields above, please print out this page. Thank you. Please send any additional information to us that would help

by email or write it down on the reverse side of the application form. Click here to return to WebRx Pharmacy Palace or

click here to return to the products page.

Patients approved for a prescription for Famotidine tablets are hereby advised that if symptoms do not improve while using this medication that

it may be a sign of a serious condition and one should seek appropriate medical attention.

By signing below I attest that I have read the above statements and have truthfully answered all questions to the best

of my knowledge and understanding:

signature / date

Your prescription, if approved, will be filled by our pharmacist. You will not be charged and your check or money order

will be returned if it is determined by the pharmacist that your request should not be approved. Mail this page with your

check or money order ($19.99 for Rx + $30 initial consult fee + s/h) payable to WebRx Pharmacy Palace to: