AdelfaRx - Salud Integral

Reordering AdelfaRx

To reorder AdelfaRx please complete the form below and click the submit button.

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Patient name

Email

Phone

Please list all the medications you are currently taking

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Medication

Medication 2

Medication 3

Medication 4

Medication 5

Dosage

Dosage 2

Dosage 3

Dosage 4

Dosage 5

Condition Prescribed For

Condition Prescribed For 2

Condition Prescribed For 3

Condition Prescribed For 4

Condition Prescribed For 5

Please provide a written commentary update: (patient overview of current medical condition, other treatments, results and any questions you may have.)

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What is your current daily dose?

Number of MONTHS supply requested

(Billing information will be sent to you via email)

Please provide current Shipping address

Reordering AdelfaRx

Please list all the medications you are currently taking

(Billing information will be sent to you via email)

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