Oral Ivermectin purchase form- Prescription NOT Required - Free Shipping - Prices as low as $37 for 5 day treatment

Pharmacy website for reference:

http://gomedicinecounter.com
Oral Ivermectin Capsules (Compounded for human use) Patient Consent Form - Prescription NOT Required - Prices are as low as $35 for 5 day treatment - HSA/FSA Cards Accepted
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

CityState

Zip Code
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)
Medical Conditions*
(Type "NONE" if there is no long term health condition) (Separate more than 1 conditions by spaces)
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 the 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 baring 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.

Purchase Products Below (IVERMECTIN SHELF LIFE - 1 YEAR 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

Ivermectine 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

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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 after 48 to 72 business hours and it will take 4 to 6 business days for delivery once shipped. 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
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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

***Orders placed without any shipping option selected will be shipped by Free USPS First Class which will take 4 to 6 business days for delivery. The pharmacy will NOT call you if you skip the shipping option step.***
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 in 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.
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Pharmacy website for reference:

Oral Ivermectin Capsules (Compounded for human use) Patient Consent Form - Prescription NOT Required - Prices are as low as $35 for 5 day treatment - HSA/FSA Cards Accepted

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

***Orders placed without any shipping option selected will be shipped by Free USPS First Class which will take 4 to 6 business days for delivery. The pharmacy will NOT call you if you skip the shipping option step.***

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

Orders placed without any shipping option selected will be shipped by Free USPS First Class which will take 4 to 6 business days for delivery. The pharmacy will NOT call you if you skip the shipping option step.