New Customer Registration Form

Personal Information
Diagnosis: Cold Sore (HSV-1)
Full Name*

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Physical Address (The address for delivery of your medications)*

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E-mail*
example@example.com
Gender*

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Date of Birth *

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Date
Are you over the age of 18? (You must be over the age of 18 to use this service.)*

YesNo

Medical Information: Have you experience a fever (100.4 F/38.0 C or higher) in the past 24-48 hours?*

YesNo
Do you have any medical conditions?*

YesNo
List all Medical Conditions. “N/A if non-applicable.”*
Are you presently taking any other medications or supplements including herbal supplements? If so, list them down below.*

YesNo
List of Allergies. “N/A if non-applicable.”*
Do you have chronic liver or kidney problems?*

YesNo
Are you pregnant or breastfeeding?*

YesNo
BY USING QUICKDOSEMEDS, YOU AGREE TO OUR IN-HOUSE PHARMACY AND DELIVERY SYSTEM. THIS ENSURES THE ACCURACY AND DELIVERY OF YOUR MEDICATIONS QUICKLY AND PRIVATELY.
Please click here to agree to use our in-house pharmacy and delivery system.*

My Products*

Cold Sore Diagnosis

$39.99

Acyclovir 400mg Take one tablet 3 times a day for 10 days.Click Here for Treatment Plan #1: (choose one plan)

$30.00 Quantity

Valacyclovir 1GM Take one tablet 2 times a day for 10 days.Click Here for Treatment Plan #2: (choose one plan)

$30.00 Quantity

Select this option ONLY for yeast infection prevention.Fluconazole 150mg Prevention of yeast infection.

$10.00 Quantity

Subtotal

$0.00

Shipping

$0.00

Total

$0.00

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Before checking out, please make sure to choose a treatment plan to ensure accurate and timely processing of your order.
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Personal Information