Oral Ivermectin Capsule and FLCCC recommended Supplements purchase form- Prescription NOT Required - Prices as low as $35 for 5 day treatment -Free shipping

***This form is exclusively for shipping within Tennessee***
FLCCC recommended Supplements and Oral Ivermectin Capsule Order form- Prescription NOT Required based on Collaborative Practice Agreement - Prices as low as $35 for 5 day treatment with FREE SHIPPING
Pharmacy website for reference:

http://gomedicinecounter.com
*** We got a new Website! ***
To enhance your experience and provide improved services, we've moved to a new website. Please click the button below to visit our new site and place your order seamlessly.
HOW TO ORDER? (Average time to complete this form is 10 min)
STEP:1 FILL OUT ALL THE INFO
STEP 2: SELECT THE CORRECT DOSAGE BASED ON WEIGHT
STEP 3: ENTER THE PAYMENT INFO, SIGN AND SUBMIT
First Name*
Middle Name
Last Name*
Date of Birth (MM/DD/YYYY)*
Gender*
(Type in "Male" or "Female"
Body Weight*
(Type in body weight in pounds)
Email*
example@example.com
Cell Phone Number*
Please enter a valid cell phone number to receive shipment tracking number via Text Message
Address*

Street Address

Street Address Line 2

City

Zip Code
TENNESSEE

State
State
State
Shipping Address (Verify Below)
Drug Allergies*
(Type "NONE" if no drug allergies) (Separate more than 1 allergies by spaces)
Current Medications*
(Type "NONE" if not taking any meds) (Separate more than 1 meds by spaces) (May enter "On File" for repeat orders)
Medical Conditions*
(Type "NONE" if there is no long term health condition) (Separate more than 1 conditions by spaces) (May enter "On File" for repeat orders)
1. Are you COVID-19 Positive?*

YESNOExposed to Covid positive patient, Test negative or pending
If positive, Enter the Date when first tested Covid-19 Positive
(Skip this step if you are not covid-19 positive )
2(a). Are you requesting Compounded Oral Ivermectin for the Treatment of Current/Active or Future Covid-19 infection? (select "Yes" for treatment, and select "No" for requesting for prevention)*

YESNO
2(b). Are you requesting Compounded Oral Ivermectin for the Treatment of Long Covid (Long Haulers/ Post Covid condition)? (select "Yes" for Long Covid-19 treatment, and select "No" for requesting for prevention)*

YESNO
3. Are you requesting Compounded Oral Ivermectin for the prevention of Covid-19 infection?*

YESNO
4. I certify that patient is NOT currently taking the following medications: Warfarin (Coumadin/Jantoven), Sirolimus(Rapamune), Tacrolimus(Advagraf XL, Envarsus XR), Erdafitinib(Balversa), Lasmiditan(Reyvow) Tepotinib(Tepmetko), Erythromycin ethylsuccinate, lactobionate, or stearate, Itraconazole, Ketoconazole, Rifampin(Rifadin), Verapamil*

YES
5. I certify that patient is at least 18 year of age or older and NOT allergic to Ivermectin.*

YES
6. I certify that patient is NOT pregnant and will not be breastfeeding while taking Ivermectin.*

YES
7. I certify that patient does NOT have Severe Asthma, Severe Liver Disease, hyperactive Onchodermatitis, Concurrent Loiasis or Onchocerciasis (Ivermectin might worsen bronchial asthma)*

YES
8. I and Patient understand that Ivermectin is NOT FDA approved to treat or prevent Covid-19 Infection. I am willing to use Ivermectin at my own risk, Patient have reviewed the medication guide on the link below (Most common side effects: dizziness, pruritis (itching on skin), nausea, or diarrhea, joint pain, muscle stiffness, swollen lymph nodes, etc) and low blood pressure, for detailed medication guide, visit: https://medlineplus.gov/druginfo/meds/a607069.html*

YES
9.I and Patient understand that there are FDA authorized therapies are available nearby for treatment of Covid-19 infection such as paxlovid, molnupiravir, and monoclonal antibodies. Patient have consulted with their Primary Care Provider to consider above treatment options before opting to receive oral Ivermectin.*

YES
10. I understand that Pharmacy custom compounds Ivermectin Sustained Release Capsule (slow release to prevent stomach upset) by using USP grade API for Human use. I will choose the correct dosage based on my weight group for treatment and/or Prevention for Covid-19.*

YES
11. I and Patient will call their primary care provider if the covid-19 infection gets worse or does not improve. I will call pharmacy if we have any questions on the possible side effects. I will call 911 and seek immediate care if I have trouble breathing, Persistent pain or pressure in the chest, New confusion, Inability to wake or stay awake, Pale, gray, or blue-colored skin, lips, nail beds, depending on skin tone, or oxygen saturation level drops below 94% or any other serious side effects*

YES
12. I and patient understands that all treatment, services and purchases are not refundable, not returnable, and not cancellable. Once the order is placed, pharmacy will not be able to cancel or refund the order. The pharmacy is not responsible for any delays caused by any technical issues or shipping companies. All sales are final. Medicine Counter Pharmacy will NOT be able to bill any form of insurance for oral Ivermectin or any OTC items purchased, I and Patient will not seek any reimbursements from Medicine Counter Pharmacy. I also agree that I or patient will not seek any reimbursement from Medicine Counter, employees, and their officers.*

YES
13. I and patient give consent to Medicine Counter pharmacy to prescribe and dispense oral ivermectin at my own request and we are bearing all risks. On behalf of myself and patient, my heirs, and personal representatives, I indemnify the organizing body and all persons connected with Medicine Counter from any and all claims that may result from my voluntary request to receive oral Ivermectin. I also agree that the pharmacy has all rights to refuse and refund any orders for any reasons.*

YES
*Ivermectin weight based dosage selection (Please read the details below)*

Please find the correct dosage based on your body weight from the table below and purchase ivermectin capsules accordingly. You may choose to select one or more recommended dose or lower dosage than recommended, however, the pharmacist will NOT approve the order if you select the dosage that is HIGHER than your body weight range from the table below.
Example # 1 (Active Infection): Covid Positive Patient who weighs 185LB: Take 1 capsule of 35mg with food once a day for 5 to 10 days until recovered.
Example # 2 (Covid Prevention): Patient who weighs 220LB and would like to take it for Covid Prevention: Take 1 capsule of 21mg Twice a week while the disease risk is high.
Example #3 (Post Exposure Prevention): Patient who is exposed to Covid positive patient and have no symptoms, and testing negative, This patient weighs 130LB: Take 1 capsule of 25mg cap with food once a day for first 2 days, then start taking 12mg capsule twice a week, if the covid symptoms starts, and still testing negative, start taking the treatment dose of 1 capsule of 25mg per day for up to 10 days.

Purchase Products Below (IVERMECTIN SHELF LIFE - 6 MONTHS FROM DISPENSE DATE)

Purchase Ivermectin Capsules Product Image

Purchase Ivermectin Capsules Please select the Ivermectin Strength and quantity (Discounted prices on larger quantities)

$35.00

Ivermectin Strength and Quantity	Quantity	Price
9 mg cap X 5 Caps		$35.00
9 mg cap X 8 Caps		$60.00
9 mg cap X 10 Caps		$80.00
9 mg cap X 14 Caps		$110.00
9 mg cap X 20 Caps		$150.00
9 mg cap X 26 Caps		$190.00
9 mg cap X 52 Caps		$365.00
9mg Cap X 100 Caps		$645.00
12 mg cap X 5 Caps		$45.00
12 mg cap X 8 Caps		$65.00
12 mg cap X 10 Caps		$80.00
12 mg cap X 14 Caps		$110.00
12 mg cap X 20 Caps		$150.00
12 mg cap X 26 Caps		$190.00
12 mg cap X 52 Caps		$365.00
12mg Cap X 100 Caps		$645.00
15 mg cap X 5 Caps		$65.00
15 mg cap X 8 Caps		$95.00
15 mg cap X 10 Caps		$110.00
15 mg cap X 14 Caps		$140.00
15 mg cap X 20 Caps		$185.00
15 mg cap X 26 Caps		$220.00
15 mg cap X 52 Caps		$390.00
15mg Cap X 100 Caps		$695.00
18 mg cap X 5 Caps		$65.00
18 mg cap X 8 Caps		$95.00
18 mg cap X 10 Caps		$110.00
18 mg cap X 14 Caps		$140.00
18 mg cap X 20 Caps		$185.00
18 mg cap X 26 Caps		$220.00
18 mg cap X 52 Caps		$390.00
18mg Cap X 100 Caps		$695.00
21 mg cap X 5 Caps		$85.00
21 mg cap X 8 Caps		$120.00
21 mg cap X 10 Caps		$130.00
21 mg cap X 14 Caps		$165.00
21 mg cap X 20 Caps		$230.00
21 mg cap X 26 Caps		$290.00
21 mg cap X 52 Caps		$530.00
21mg Cap X 100 Caps		$895.00
25 mg cap X 5 Caps		$85.00
25 mg cap X 8 Caps		$120.00
25 mg cap X 10 Caps		$130.00
25 mg cap X 14 Caps		$165.00
25 mg cap X 20 Caps		$230.00
25 mg cap X 26 Caps		$290.00
25 mg cap X 52 Caps		$530.00
25mg Cap X 100 Caps		$895.00
30 mg cap X 5 Caps		$85.00
30 mg cap X 8 Caps		$120.00
30 mg cap X 10 Caps		$130.00
30 mg cap X 14 Caps		$165.00
30 mg cap X 20 Caps		$230.00
30 mg cap X 26 Caps		$290.00
30 mg cap X 52 Caps		$530.00
30mg Cap X 100 Caps		$895.00
35 mg cap X 5 Caps		$110.00
35 mg cap X 8 Caps		$150.00
35 mg cap X 10 Caps		$165.00
35 mg cap X 14 Caps		$230.00
35 mg cap X 20 Caps		$320.00
35 mg cap X 26 Caps		$410.00
35 mg cap X 52 Caps		$745.00
40 mg cap X 5 Caps		$110.00
40 mg cap X 8 Caps		$150.00
40 mg cap X 10 Caps		$165.00
40 mg cap X 14 Caps		$230.00
40 mg cap X 20 Caps		$320.00
40 mg cap X 26 Caps		$410.00
40 mg cap X 52 Caps		$745.00
45mg cap X 5 Caps		$110.00
45mg cap X 8 Caps		$150.00
45mg cap X 10 Caps		$165.00
45mg cap X 14 Caps		$230.00
45mg cap X 20 Caps		$320.00
45mg cap X 26 Caps		$410.00
45mg cap X 52 Caps		$745.00

Item subtotal:$0.00

CofixRX Nasal Cleanse Spray (Made in USA) Product Image

CofixRX Nasal Cleanse Spray (Made in USA)A nasal hygiene solution designed to support clean and healthy nasal passages, making it ideal for travel, recreational activities, and gatherings. CofixRX uses a patented formula with ingredients known for their safety and effectiveness. Use to help reduce exposure to airborne contaminants and protect your upper respiratory tract. (Ingredients: Purified Water, Povidone-Iodine, Xylitol, Vitamin D3, Polysorbate, Gellan Gum, Natural Carrageenan, Citric Acid, Sodium Citrate, Glycerin, Disodium Phosphate, Sodium Hydroxide). Shake vigorously before use, and follow the recommended dosage for adults and children.

$19.99 Quantity

Povidone Iodine 1% - Oral Cleanse Spray (Made in USA) Product Image

Povidone Iodine 1% - Oral Cleanse Spray (Made in USA)Help stop the spread, rinse your throat and mouth to wash away germs and defend the entryway to your upper respiratory tract and lungs. (May help clear many types of infections including, strep throat, upper respiratory, etc)Use as directed with the ImmuneMist™ Nasal Cleanse to double your layers of protection. Includes up to 250 doses. (Ingredients: Povidone Iodine, Citric Acid Monohydrate, Sodium Citrate Dihydrate, Sucralose, Potassium Lodide, Glycerine, WS-23 (Cooling agent), Raspberry Flavor, Purified Water. ImmuneMist is a tea-colored liquid.)

$19.99 Quantity

Chlo Hist Cough Syrup (120ml) (best cough syrup)

$18.00 Quantity

B&T Daytime Cough & Bronchial Syrup Homeopathic, 4 Oz.

$20.00 Quantity

B&T Nighttime Cough & Bronchial Syrup for Restful Sleep Homeopathic, 4 Oz.

$20.00 Quantity

Berberine 400mg capBerberine is found in nature in the following plants: European barberry, Goldenseal, Goldthread, Oregon grape, Phellodendron, and Tree tumeric.Berberine has been used in Eastern medicine for years to treat Diabetes mellitus.Berberine has many positive health effects:Helps reduce blood sugar levelsHelps lower cholesterolSupports the mitochondria in the cellsHelps lower blood pressure by increasing nitric oxide production in the inner tissue lining of the blood vesselsBerberine has anti-inflammatory properties and can change or influence the gut bacteria in the microbiomeThe inflammation caused by Testosterone in Polycystic ovary disease (PCOS) can also be reduced with the help of Berberine

$20.00 Quantity

N95 Particulate Respirator Face Mask by 3M (Each)

$3.50 Quantity

Elderberry + Vit C + Zinc (60 vegan Gummy) Product Image

Elderberry + Vit C + Zinc (60 vegan Gummy) IMMUNE SUPPORT: 60-count, 100mg Elderberry Gummies for immune support.* Elderberries have a long history of use, especially as a food. Nature’s Bounty Elderberry Gummies contain 100mg of this naturally occurring flavonoid. ANTIOXIDANT SUPPORT: Nature’s Bounty Gummies are an easy way to get the supplements your body needs for immune support.* Nature’s Bounty Elderberry Gummies are a delicious and gelatin free way to reap the benefits of the Elderberry & Vitamins A,C,D,E plus Zinc QUALITY, PURITY, POTENCY: Nature’s Bounty is committed to safety and purity in all our supplements. Our Elderberry Gummies are sugar and gluten-freeFROM THE TRUSTED WELLNESS EXPERTS: Nature’s Bounty Elderberry Gummies bring together science, nature and a 50 year dedication to quality, consistency and scientific research for vitamins and nutritional supplements of unrivaled excellence

$18.00 Quantity

Vit B-complex plus B12 high potency (90ct) Product Image

Vit B-complex plus B12 high potency (90ct)(You may receive a substituted brand if the pictured brand is not available)

$10.00 Quantity

Black Cumin Seed Oil (Nigella Sativa) 500mg cap (60 Cap) Product Image

Black Cumin Seed Oil (Nigella Sativa) 500mg cap (60 Cap)(You may receive a substituted brand, if the pictured brand is not available)

$12.00 Quantity

Cetirizine 10mg Tab (Generic Zyrtec) (30 tab) Product Image

Cetirizine 10mg Tab (Generic Zyrtec) (30 tab) For Allergies, runny nose, sneezing, itchy throat, nose

$6.00 Quantity

Cetirizine 10mg Tab (500 tabs)

$34.99 Quantity

Vitamin C 500mg tab (100 tab)

$6.00 Quantity

CoQ10 cap 100mg (30 cap)Serving Information Serving Size: 1 softgel 100 mg per serving 50 servings per container softgel size: E Product Description Promotes cardiovascular and nervous system health and muscle and physical endurance Supports antioxidant activity while also helping maintain healthy blood sugar levels Helps keep cells healthy and energized Easy-to-swallow softgels Help support heart function with Swanson Ultra Coenzyme Q10! Also known as ubiquinone, CoQ10 produces adenosine triphosphate (ATP) in the body. Each softgel delivers 100 mg of CoQ10.

$14.00 Quantity

Dandelion Root 515mg Cap (60 Cap)

$12.00 Quantity

L-Glutathione 100mg cap (100caps)

$20.00 Quantity

Neuropaway NeuropAWAY Nerve Support, Clinically Proven Patented Formula for Nerve Discomfort, Burning (60 Caps) Product Image

Neuropaway NeuropAWAY Nerve Support, Clinically Proven Patented Formula for Nerve Discomfort, Burning (60 Caps)May Help you recover from headaches and migraine from Long Covid

$22.00 Quantity

Quercetin + Vitamin C Complex 250mg (50 Caps) Product Image

Quercetin + Vitamin C Complex 250mg (50 Caps)(You may receive a substituted brand if the pictured brand is not available)

$20.00 Quantity

NAC ( N-Acetyl Cysteine 600mg cap (100 Ct) Product Image

NAC ( N-Acetyl Cysteine 600mg cap (100 Ct)(You may receive a substituted brand if the pictured brand is not available)

$16.00 Quantity

Mullein Leaf Extract 250mg cap (60 caps)

$12.00 Quantity

Melatonin 3mg tab (60 tab)

$8.00 Quantity

Melatonin 5mg Tab (90 Tabs)

$12.00 Quantity

ULTIMATE STRAIN PROBIOTIC WITH FOS (BIFIDOBACTERIUM. BIFIDUM) Product Image

ULTIMATE STRAIN PROBIOTIC WITH FOS (BIFIDOBACTERIUM. BIFIDUM)Dr. Stephen Langer's Ultimate 16 Strain Probiotic from Swanson Probiotics includes more than four times the number of strains and over twice the number of CFUs compared to many popular probiotic formulations marketed in clinics and pharmacies today. While many popular supplements provide only two strains of bifidobacteria, Dr. Langer's formula delivers four.

$15.00 Quantity

Resveratrol 100mg Cap (30 Cap)

$16.00 Enter Quantity to Add in Cart

Pine Needle Oil (essential oil) 30ml

$16.00 Quantity

Vitamin K2 100MCG (100 TABS)

$10.00 Quantity

Turmeric Curcumin complex 500mg Cap (120 CT)

$17.99 Quantity

Ultimate Immune Defense (VIT C + Zinc + Vit D + Elderberry) (60 Capsules)

$18.00 Quantity

Zinc Picolinate 22mg Cap (Body Preffered Form) (60 Cap)

$8.00 Quantity

Digital Thermometer (Under Tongue) Product Image

Digital Thermometer (Under Tongue)(You may receive a substituted brand if the pictured brand is not available)

$6.00 Quantity

IHealth Rapid At-Home Covid Test - 2PK Product Image

IHealth Rapid At-Home Covid Test - 2PK(You may receive a substituted brand if the pictured brand is not available)

$20.00 Quantity

Infrared Forehead Thermometer Product Image

Infrared Forehead Thermometer(You may receive a substituted brand if the pictured brand is not available)

$28.00 Quantity

Finger Pulse Oximeter (You may receive a substituted brand if the pictured brand is not available)

$30.00 Quantity

Nebulizer (You may receive a substituted brand if the pictured brand is not available)

$58.00 Quantity

Select Correct Shipping or Curbside Pick-up option Below Product Image

Select Correct Shipping or Curbside Pick-up option BelowDo NOT Enter a PO BOX Address above if you choose UPS or FEDEX below. Same day shipping cut off time is 3:00pm EST on Monday to Friday and 1:00PM EST on Saturday. Order placed between 3:01pm - 4:00pm EST may or may NOT ship the same day. The Pharmacy is closed on Sunday and all major holidays. All orders placed after cut off time will ship on next business day. UPS does not deliver or pick-up orders on Saturday, please choose Fedex in that case. Free shipping orders are currently shipping within 3 business days. Curbside Pick-up Patients MUST wait for a text message alert notifying the Medicine is ready for CURBSIDE Pick-up before arriving at the pharmacy. (DO NOT ENTER INSIDE THE PHARMACY)

$ Free Shipping Speed
Item subtotal:$0.00

Enter coupon

Total

$0.00

Debit/Credit/HSA/FSA Payment Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

***The pharmacy will NOT call you if you skip the shipping option step. We will ship your package with free shipping***
14. I agree that I have selected a CORRECT SHIPPING or CURBSIDE pickup option above. I also agree that I or the person picking up curbside order (if applicable) will NOT enter INSIDE the pharmacy.*

YES
Signature of Patient receiving Ivermectin Treatment (Use Mouse left click and drag to draw to the signature, or use finger and draw if its touch screen device)
Signature*

Clear
Date*

MonthDayYear
Click submit to complete the order. Although Rarely, If the transaction declines on the next window, check for text, phone, app, or email alert from the credit card company. If you don't receive any alert, please call the credit card company to verify the transaction and try again. If you don't see thank you page next after clicking submit, please clear cookies and caches of your browser by going inSave TOOLS tab of your browser, then clear browsing data. Should you still need further assistance, Please call the pharmacy during business hours at 423-680-7373. Thank you.
Should be Empty:

***This form is exclusively for shipping within Tennessee***

FLCCC recommended Supplements and Oral Ivermectin Capsule Order form- Prescription NOT Required based on Collaborative Practice Agreement - Prices as low as $35 for 5 day treatment with FREE SHIPPING

Pharmacy website for reference:

*** We got a new Website! ***

To enhance your experience and provide improved services, we've moved to a new website. Please click the button below to visit our new site and place your order seamlessly.

HOW TO ORDER? (Average time to complete this form is 10 min)

STEP:1 FILL OUT ALL THE INFO

STEP 2: SELECT THE CORRECT DOSAGE BASED ON WEIGHT

STEP 3: ENTER THE PAYMENT INFO, SIGN AND SUBMIT

TENNESSEE

*Ivermectin weight based dosage selection (Please read the details below)*

Example # 1 (Active Infection): Covid Positive Patient who weighs 185LB: Take 1 capsule of 35mg with food once a day for 5 to 10 days until recovered.

Example # 2 (Covid Prevention): Patient who weighs 220LB and would like to take it for Covid Prevention: Take 1 capsule of 21mg Twice a week while the disease risk is high.

***The pharmacy will NOT call you if you skip the shipping option step. We will ship your package with free shipping***

This form is exclusively for shipping within Tennessee

* We got a new Website! *

Ivermectin weight based dosage selection (Please read the details below)

The pharmacy will NOT call you if you skip the shipping option step. We will ship your package with free shipping