Request for generic Allegra 60mg tablets (quantity 60) 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):

Describe your 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.  If symptoms do not improve after a reasonable time please consult with a 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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