PharmacyHealth.net Medical Questionnaire/Order Request
	The information below is needed to place your order request for medication. We will not disclose any personal information to any outside party. See our privacy statement for additional information. All fields below must be filled out for order requests.

	Section 1:	customer account information
		First Name:	(Complete First Name - No Initials)
		Last Name:
		Email Address:	(Like yourname@aol.com)
			NOTE: To keep you informed, we provide e-mail notifications concerning your medical consultation and order status.
		Date of Birth:	Month 01 02 03 04 05 06 07 08 09 10 11 12 / Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Year 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902
		Gender:	--Select-- Male Female

	Section 2:	shipping/contact information
		Shipping Method: