Morris Medical - Home Page


	Order Forms
		Prescriptions
		Rx-Refills
		Consulting
	Info Center
		Health Tips
		Pharmacy-Finder
		Med Links
		Site Map
		Home

	Account Manager
		Log-in
		Mail Box
		My Records
		Reports

	About Us
		Our Mission
		F.A.Q.
		Policy Statements
		Contacts


	Celebrex^® Prescription Consultation

Review and update your account information.

Use the Account Manager to view your current records. If any personal or medical information has changed since your last visit, please update and re-submit your records before continuing. Be sure to check that your general information, medical history, current medications, and allergy charts are all up-to-date.

Complete the following medical review.

The questions below are specific to receiving a Celebrex^® prescription. This information will be evaluated in conjunction with your general medical records from "Step 1". Please answer all questions truthfully and completely, to the best of your knowledge.

Where do you want to purchase this medication?

Store #

What dosage and/or treatment duration are you requesting?

What is your current weight?

lbs.

What is your height?

Have you had a complete physical exam with blood tests within the last year?

Yes No

How is your blood pressure?

Have you taken this medication before?

Yes No

If yes, did you have any side effects when you last took this product?

Do you have any questions or concerns about this product and your health?

The physician needs a specific reason for ordering this medication. In order to prescribe this medication the physician must know the exact nature of your medical problem. What is currently bothering you about your health?

Females in their childbirth years should avoid this medication due to possible birth defects. I am over the age of 50, have had a hysterectomy or tubal ligation, or have menopaused.(if you are male, leave blank.)

Yes No

Are you currently taking any of the following medications?

None	Steriods	Fluconozole
Warfarin	Diflucan	Diuretics/ Water pills (Diazide, Lasix, etc.)
Lithium	Cumodin		Non Steriodal anti-inflammatory medication (aspirin, advil, etc.)

Verify your order.

You certify that all account information is current, accurate, and complete?

Yes No

You are requesting the prescription medication(s) solely for your own personal therapeutic and medical needs, and will not distribute any of the medication to others?

Yes No

You will promptly contact a local physician for any necessary medical intervention should a complication or concern result related to the use of a requested medication?

Yes No

You realize there are risks as well as benefits to any medication, even non-prescription drugs. You have been informed of the possible effects, risks, and benefits of this medication?

Yes No

You understand the side-effects of these pills?

Yes No

You understand that you can not have a Celebrex^� prescription from more than one physician?

Yes No

You understand that you are ordering a prescription consultation and the fee charged for the consultation is non-refundable and does not include the cost of any medication?

Yes No

You understand that Morris Medical Online Services, Inc. does not guarantee that you will receive a prescription for any medication.

Yes No

You certify that I have and will answer all the questions truthfully?

Yes No

I have answered all questions truthfully,
I have read and agree to the Waiver of Liability
I am legally entitled to receive Celebrex^�

Comments: