Anvirzel® - Salud Integral

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Reorder Anvirzel

Patients requesting an additional supply of Anvirzel® are required to provide updated medical records and updated patient information.

Please complete the form below and click the submit button.

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Patient name

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.)

Patients are required to send any updated medical records and/or laboratory results since their last Anvirzel® order

Will you be sending your medical records?

Yes
No
I have sent most current records

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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:

Reorder Anvirzel

Please list all the medications you are currently taking:

Patients are required to send any updated medical records and/or laboratory results since their last Anvirzel® order

(BILLING INFORMATION WILL BE SENT TO YOU VIA EMAIL)

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