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.

Patient name

Phone

Please list all the medications you are currently taking:

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

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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