Order Here Please provide the following medical information. All fields are required. First Name *: Last Name *: Street Address: City: State: Zip: StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Email *: Phone: xxx-xxx-xxxx Please select your prescription: (required) ------- Select Your Order --------Butalbital/APAP/Caf 90 Tabs 50/325/40mg $198.50Butalbital/APAP/Caf 90 Tabs 50/325/40mg $268.50Butalbital/APAP/Caf 180 Tabs 50/325/40mg $289.50Tramadol 50mg (Gen. for Ultram) 90 Tabs out of stockTramadol 50mg (Gen. for Ultram) 180 Tabs out of stock Date of Birth: MonthJanFebMarAprMayJunJulAugSepOctNovDecDay01020304050607080910111213141516171819202122232425262728293031Year1995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920191919181917191619151914191319121911191019091908190719061905190419031902 Gender: SelectMaleFemale Height: FT'-IN"4' 0"4' 1"4' 2"4' 3"4' 4"4' 5"4' 6"4' 7"4' 8"4' 9"4' 10"4' 11"5' 0"5' 1"5' 2"5' 3"5' 4"5' 5"5' 6"5' 7"5' 8"5' 9"5' 10"5' 11"6' 0"6' 1"6' 2"6' 3"6' 4"6' 5"6' 6"6' 7"6' 8"6' 9"6' 10"6' 11"7' 0"7' 1"7' 2"7' 3"7' 4"7' 5"7' 6"7' 7"7' 8"7' 9"7' 10"7' 11" Weight: (lbs) I agree not to take any over-the-counter medicines without approval from my pharmacist I AgreeI Disagree If you disagree, please explain why: I agree not to take medication if I am pregnant, breast-feeding, or trying to get pregnant. I AgreeI Disagree If you disagree, please explain why: Please list all current medical conditions. Choose "None" if none. NoneI will specify Is there anything in your medical history that you consider to be relevant? If yes, please specify. Choose "None" if none. NoneI will specify Please list all over-the-counter and prescription medications that you are currently taking and the length of time for each. Choose "None" if none. NoneI will specify Please list all medications that you plan to take while on this program. Choose "None" if none. NoneI will specify Please list all past or present allergies including allergies to any medications. Choose "None" if none. NoneI will specify Please list all past surgeries and provide details including the condition that was treated with each surgery. Choose "None" if none. NoneI will specify 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.(This cannot be left blank.) All the information is correct and I agree to pay using my credit card.