Step
Request for Astelin Nasal Spray Prescription:
This information is necessary in order to process your request for your prescription. Please answer all questions
completely and truthfully. All fields are required. Patients are advised that if after using the medication and
symptoms do not improve to seek medical advice from a physician.
Last Name:First:Middle:DayPhone:
Email Address: EvePhone:
Address:City:State:Zip:
Notice: We do NOT ship prescription medicines to residents of Missouri Note to international clients: Country selection is located on the payment & shipping page.
Notice: We do NOT ship prescription medicines to residents of Missouri
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:
Chief Current Complaint (e.g. allergies):
Please describe your symptoms:
How often do symptoms occur?
How long ago did you first experience these symptoms?
Do you suffer from bronchial asthma, or other lower respiratory conditions, glaucoma, any cardiovascular disorders, hypertension, prostate conditions, or urinary retention?
Yes No
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Patients are hereby advised that Astelin should not be used by patients with bronchial asthma or other lower respiratory symptoms, glaucoma, cardiovascular disorders, hypertension, prostate conditions or urinary retention, or children under 12 years old. By clicking the continue button below I state that I have answered all questions truthfully to the best of my knowledge and ability.
This is a secure pageIf you would prefer to fax the information please print, click reset, and fax it to (941)296-7447 then click here to make payment. Privacy Statement: No information is collected until the Continue button is clicked. All information provided is kept in strict confidence and will NOT be sold or shared with anyone unless it is directly related to the prescribing, dispensing, or shipment of your medication.
This is a secure page
If you would prefer to fax the information please print, click reset, and fax it to (941)296-7447 then click here to make payment.
Privacy Statement: No information is collected until the Continue button is clicked. All information provided is kept in strict confidence and will NOT be sold or shared with anyone unless it is directly related to the prescribing, dispensing, or shipment of your medication.