In order for one of our licensed physicians to prescribe medication, we need to first know more about you and your condition. Please take a moment to fill out the following online medical health profile. A BestQualityHealth Customer Service Representative will call you shortly after you complete the medical health profile in order to verify your identity and schedule your medical consultation. At this time we are offering a direct prescription program and have two options available. The first consult option costs $180.00. If your records are approved, your prescription will be sent to you via overnight Fedex with the initial fill and two refills. The second option costs $245.00. If your records are approved, one of our licensed physicians will then call your prescription into the local pharmacy of your choice for you to pick up. This prescription option also includes the initial fill and 2 refills. Once we receive payment, you will be scheduled for your consultation and will receive a phone call from an assigned physician within 24 hours. Doctors are available Monday through Friday (9:00am-4:00pm EST). Information will be treated confidentially and will not be released to third parties. For additional information on how we protect your privacy, please review our privacy statement.

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Have you had a complete physical exam with blood tests within the last year?
Select Yes No

Do you have high blood pressure or are you currently being treated for high blood pressure?
Select Yes No

I agree to monitor my blood pressure at least once every 14 days. If my blood pressure is over 140/90 (either the top number is greater than 140 or the bottom number is greater than 90), I agree to stop taking medication(s) prescribed by our doctor immediately.

Select Yes No

I agree to consult my pharmacist before taking any over-the-counter medications.

Select Yes No

I agree not to take any medication prescribed by our doctor, if I am pregnant, breast feeding, or trying to get pregnant.

Select Yes No

I agree to allow the physician to leave a message at my consultation phone number?

Select Yes No

I agree not to take this medicine if I have any history of liver or kidney disease.

Select Yes No

I agree not to take this medicine if I have any history of asthma or allergic-type reactions to aspirin or non-steroidal compounds.

Select Yes No

I agree not to take this medication if I have a history of seizures.

Select Yes No

I agree not to take this medicine if I have any history of heart failure, fluid retention, or uncontrolled hypertension.

Select Yes No

I agree not to take this medicine if I have any history of ulcer disease, bleeding, or symptoms of gastrointestinal disease such as gnawing or burning stomach pain, black or tarry stools or vomiting. I also agree to notify my health care provider if I experience any of the above symptoms.

Select Yes No

Your level of pain:
On a scale of 1 - 10 with 1 being 'mild pain' and 10 being 'severe pain', please indicate how you would rate your level of pain.

Select 1 2 3 4 5 6 7 8 9 10

Please indicate the duration of the pain:

Selected 0-6 months 6 months - 1 year greater than 1 year

Please indicate the location of the pain:

Please list all past and current allergies, including allergies to medications: (Enter "None", if you have no allergies)

Please list all over-the-counter and prescription medications you are currently taking: (Enter "None", if you are taking no other medications)

Please list all medications that you plan to take while on this medication:
(Enter "None", if you do not plan to take any other medications)

Please list all surgeries, including those in the past and any anticipated in the future: (Enter "None", if you have not had any previous surgeries or none are expected in the future)

Is there anything else in your medical history you deem relevant?
(Enter "Nothing", if you have no other relevant medical history)

Please explain in detail your current medical condition(s), for which you are requesting this medication. The physician must understand your medical problem in order to prescribe this medication. This cannot be left blank.