Please enter the drug you would like to order: First-Time Order: Yes No Dosage: How many times per day medication taken: Do you want a generic brand? Yes No So, that we can check for any incompatibilities, please enter your current medications: Name: Dose: Frequency: Any drug allergies:
If this is a new prescription, Medtreon will need to confirm this order with your physician: Name: Address: Phone: Fax: email:
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