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First Name *

Middle Initial *

Last Name *

Date of Birth *

Email Address *

Contact Number *

House/Unit Number, Street *

City *

State / Province *

ZIP / Postal Code *

If Billing is same as Shipping AddressYesNo

Shipping Method *UPS 2nd Day Air $39.95UPS Ground $19.95

Billing Address *

City *

ZIP / Postal Code *

Medication *If your medication is not listed, please select N/A.

Promo Code

State / Province *

Total

$

Medical Questionnaire:

1. Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. *

2. Is your current physician aware of your ordering of this medication? (Yes or No) *

3. How often do you take this medication? *

4. Do you have allergies? *

Specify Allergies *

5. Do you have any active medical conditions or comorbidities? *

State existing conditions or comorbidities *

6. Do you have any past medical and psychiatric conditions including any surgery or other procedures? *

State past medical and psychiatric conditions *

7. Are you taking any other medications? If yes, please list all prescription and over-the-counter medications that you are currently taking and the length of time for each. *

Specify other medications and length of time *

8. Do you smoke or consume alcohol in excessive amounts? *

9. Are you currently or within the last 12 months been pregnant or nursing? Do you plan on getting pregnant soon? *If your gender is female please answer the question. Otherwise type "none".

10. Do you have a condition called Porphyria? *

Payment Method *

Email Address *An invoice will be sent to this email address for the payment. A convenience fee of $4 is added with this mode of payment.

Full Name *

Bank Account No. *

Check Number *

Routing Number *

City *

State/Province *

Zelle Confirmation Code *You may send your payment to payments@mlocker.me then input the confirmation code.

Total

$

I have read, understand, and agree with the privacy policy and terms and conditions.

I have read, understand, and agree with the Customer Responsibility Statement .

I have read, understand, and agree with the Informed Consent Statement .

Yes, I agree with the Deduction Authorization.

I agree that Medlocker keeps my information on file as reference to my future orders.

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