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estriol vag cr RX req

Estriol Vag Cr RX Request

Please fax my doctor a note requesting a prescription for Estriol Vaginal Cream for me.

My name is:

My Age & Birthdate are:

Address

Day time phone#

Cell Phone #

Home Phone #

Drug Allergies

Check any of the following problems that you are hoping will improve with the Estriol Cream

Vaginal Dryness

Please check the severity

mild moderate severe

Recurrent Vaginal Infections

Please check the severity

mild moderate severe

Incontinence

Please check the severity

mild moderate severe

Have you had a hysterectomy?

YES NO

Are you in menopause

YES NO

Name of Dr. you want us to fax this request to

Doctor's Phone # or where they practice

We will take this information and fax a note to your doctor requesting a prescription for Estriol Vaginal Cream for you. When we hear back from the doctor, we will contact you.

3349 Highway 31, Suite 102
Homewood, AL 35209
Office 205-870-3150
Fax 205-870-3160
E-mail Us

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