Request for Famotidine 40mg Prescription (established client):

Last Name:First:Middle:DayPhone:

Email Address: EvePhone:

Address:City:State:Zip:

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):

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 are hereby advised that if symptoms do not improve while using this medication that it may be a sign of a serious condition and 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