Proctozone-HC Order Form

Proctozone-HC Medical Questionnaire, New Client

Patients are advised that if after using the medication and symptoms do not improve to seek medical advice from a physician.
Within the United States, this item can only be shipped to Florida residents.

Your Basics

Last Name
First Name
Middle Initial
Gender
1. MALE
2. FEMALE
Date of Birth
Email Address
Landline Phone
Cel Phone

Medical History

Pregnant or Nursing?
What medications are you taking?
List allergies to medications
What chronic diseases or medical conditions do you have?
For what purpose are you requesting this medication?
How long have you had the condition that you need treatment for?
On what part of the body will you use this medication?
What else are you using to treat your condition?
How did you find RxPalace.com?