Request for generic Allegra 60mg Tablets Prescription:

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:

Chief Current Complaint (e.g. allergies):

Do you suffer from bronchial asthma, or other lower respiratory conditions, glaucoma, any cardiovascular disorders, hypertension, prostate conditions, or urinary retention?

Yes  No

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 previous page.

Patients are hereby advised that Allegra should not be used by patients with bronchial asthma or other lower respiratory symptoms, glaucoma, cardiovascular disorders, hypertension, prostate conditions or urinary retention.  If symptoms do not improve please contact your physician.

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:

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