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

Pharmacy website for reference:

http://gomedicinecounter.com
FLCCC recommended Supplements and Oral Ivermectin Capsule purchase form- Prescription NOT Required - Free Shipping - Prices 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
Shipping Address*

Street Address

Street Address Line 2

CityState

Zip Code
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)
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 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 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

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

Povidone Iodine 1% - Nasal Cleanse Spray (Made in USA)Help stop the spread, rinse your nasal passage to wash away germs and defend the entryway to your upper respiratory tract and lungs (May help clear many types of infections including sinus, strep throat, upper respiratory, etc). Use as directed with the ImmuneMist™ Oral Cleanse to double your layers of protection. Includes up to 250 doses. (Ingredients: Povidone Iodine, Citric Acid Monohydrate, Sodium Citrate Dihydrate, Sodium Chloride, Polysorbate 80, Glycerine, WS-23 (Cooling Agent), Raspberry Flavor, Purified Water. ImmuneMist is a tea-colored liquid)

$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.)

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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

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N95 Particulate Respirator Face Mask by 3M (Each) Product Image

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$4.50 Quantity

Elderberry + Vit C + Zinc + Vit D (40 vegan Gummy) by Nature's Bounty Product Image

Elderberry + Vit C + Zinc + Vit D (40 vegan Gummy) by Nature's Bounty(You may receive a substituted brand if the pictured brand is not available)

$16.00 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

Vitamin B-Complex 100 Tme release (ultra high dose) (60 tab)

$14.00 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 (300 tabs) (1 year supply)

$25.00 Quantity

Vitamin C 500mg tab (100 tab)

$6.00 Quantity

Co-Q-1 0 50mg cap (30 cap)

$10.00 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

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$22.00 Quantity

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

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

$18.00 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

PEAK ATP CELLUAR ENERGY AND CIRCULATORY HEALTH Product Image

PEAK ATP CELLUAR ENERGY AND CIRCULATORY HEALTHADENOSINE 5'-TRIPHOSPHATE DISODIUM

$24.00 Quantity

Melatonin 3mg tab (60 tab)

$8.00 Quantity

Melatonin 5mg Tab (90 Tabs)

$12.00 Quantity

PQQ 20MG (CELLUAR ENERGY AND BRAIN HEALTH) 30 CAPS Product Image

PQQ 20MG (CELLUAR ENERGY AND BRAIN HEALTH) 30 CAPSPYRROLOQUINOLINE QUINONE DISODIUM SALT

$24.00 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 SIX (JAPANESE KNOTWEED) 60 CAPS

$20.00 Quantity

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 & D + Zinc + Elderberry) (60 Caps)

$18.00 Quantity

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

$8.00 Quantity

Zinc Gluconate Chelated 50mg tab (90 Tab)

$10.00 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

Flowflex Covid-19 Rapid At Home Test Kit Product Image

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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 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
Item subtotal:$0.00

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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:

FLCCC recommended Supplements and Oral Ivermectin Capsule purchase form- Prescription NOT Required - Free Shipping - Prices 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.