Refill – Secure Medlocker

Skip to content

Home
Featured Products
Product Category
About Us

Home
Featured Products
Product Category
About Us

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 *USPS Priority $19.95USPS Express $49.95UPS 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 *

I consent for Always Pharmacy to become the direct service and billing provider for my prescriptions, to contact me directly regarding medications and payments, and for Medlocker to share necessary health and billing information with AP Pharmacy for treatment and payment purposes, in compliance with HIPAA. *

I agree to switch my pharmacy provider to Always Pharmacy. *

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 gaile@marconjohnsolutions.com 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.

GET STARTED

Home
Shop Products
Testimonials

Home
Shop Products
Testimonials

ABOUT US

Company Info
Contact Us

Company Info
Contact Us

TERMS

Terms & Conditions
Legal Disclaimer
Privacy Policy
Return Policy
Refund Policy

Terms & Conditions
Legal Disclaimer
Privacy Policy
Return Policy
Refund Policy