Oral Ivermectin purchase form- Prescription NOT Required - Free Shipping

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 State

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? *

YES NO Exposed 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. Are you requesting Compounded Oral Ivermectin for the Treatment of Current/Active, Future, or Past (Long Haulers) Covid-19 infection? (select "Yes" for treatment, and select "No" for requesting for prevention) *

YES NO

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

YES NO

4. I certify that patient is NOT currently taking Warfarin/Coumadin/Jantoven *

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), 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% *

YES

12. I and patient understands that all treatment, services and purchases are not refundable and not returnable, 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 all claims that may result from my voluntary request to receive oral Ivermectin *

YES

My Products

Purchase Ivermectin Capsules Shelf life 1 year in future from dispense date Please select the Ivermectin Strength and quantity (Discounted prices on larger quantities)

Ivermectine Strength and Quantity	Quantity	Price
9 mg cap X 5 Caps		$ 45.00
9 mg cap X 8 Caps		$ 65.00
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
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
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
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
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
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
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
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 - Nasal Cleanse Spray - by ImmuneMist Help stop the spread, rinse your nasal passage to wash away germs and defend the entryway to your upper respiratory tract and lungs. 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 - Oral Cleanse Spray - by ImmuneMist Help stop the spread, rinse your throat and mouth to wash away germs and defend the entryway to your upper respiratory tract and lungs. 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

Boericke & Tafel Cough and Bronchial Syrup with Zinc - 4 fl OZ (Best Natural homeopathic cough syrup)

$ 14.00 Quantity

Boericke & Tafel Nighttime Cough and Bronchial Syrup - 4 fl OZ (Best Natural homeopathic cough syrup)

$ 14.00 Quantity

Chlo Hist (120ML) (Best Cough Syrup)

$ 18.00 Quantity

Vitamin D3 5000 IU Tab (100 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 10.00 Quantity

Vitamin D3 2000 IU Tab (100 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 10.00 Quantity

Vitamin C 500mg Tab (100 Tab) (You may receive a substituted brand, if the pictured brand is not available)

$ 8.00 Quantity

Aspirin 81mg (120 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 4.00 Quantity

Aspirin 325mg (100 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 4.00 Quantity

Zinc 50mg (100 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 10.00 Quantity

Melatonin 3mg (60 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 8.00 Quantity

Melatonin 5mg (120 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 9.00 Quantity

Acetaminophen 500mg (50 Tab) (You may receive a substituted brand, if the pictured brand is not available

$ 4.00 Quantity

Turmeric/Curcumin Complex 500mg (120 Cap) (You may receive a substituted brand, if the pictured brand is not available

$ 18.00 Quantity

Turmeric Curcumin 1500mg complex per serving (60 ct) (You may receive a substituted brand if the pictured brand is not available)

$ 16.00 Quantity

Sambucol (Black Elderberry) (120 ml) (You may receive a substituted brand, if the pictured brand is not available

$ 15.00 Quantity

Sambucus Black Elderberry + Vit C + Zinc (50 vegan Gummy) by Nature's Truth (You may receive a substituted brand if the pictured brand is not available)

$ 16.00 Quantity

Black Cumin Seed (Nigella Sativa) 400mg (60 Caps) (You may receive a substituted brand if the pictured brand is not available

$ 10.00 Quantity

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

$ 10.00 Quantity

L-Glutathione 100mg cap (100caps)

$ 15.00 Quantity

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

$ 16.00 Quantity

Mullein Leaf 500mg cap 90 caps by Nature's Ans

$ 18.00 Quantity

Mullein Leaf Extract 250mg cap (60 caps)

$ 12.00 Quantity

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

$ 10.00 Quantity

Pine Needle Oil (essential oil) 30ml

$ 14.00 Quantity

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

$ 6.00 Quantity

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

$ 28.00 Quantity

Flowflex Covid-19 Rapid At Home Test Kit (You may receive a substituted brand if the pictured brand is not available)

$ 15.00 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

Shipping or Curbside Pick-up option 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 hours and it will take 3 to 5 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

Total

$ 0.00

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Expiration Month	Expiration Year
Billing Address
Street Address
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City	State / Province
Postal / Zip Code	Country

DON'T FORGET TO CHOOSE THE CORRECT SHIPPING OPTION ABOVE.

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)

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Date *

Pharmacy website for reference:

Oral Ivermectin Capsules (Compounded for human use) Patient Consent Form - Prescription NOT Required - Prices are as low as $45 for 5 day treatment

Ivermectin weight based dosage selection

Orders placed without any shipping option selected will be shipped by Free USPS First Class which will take 3 to 5 business days for delivery. The pharmacy will NOT call you if you skip the shipping option step.

Pharmacy website for reference:

Oral Ivermectin Capsules (Compounded for human use) Patient Consent Form - Prescription NOT Required - Prices are as low as $45 for 5 day treatment

Ivermectin weight based dosage selection

***Orders placed without any shipping option selected will be shipped by Free USPS First Class which will take 3 to 5 business days for delivery. The pharmacy will NOT call you if you skip the shipping option step.***

Orders placed without any shipping option selected will be shipped by Free USPS First Class which will take 3 to 5 business days for delivery. The pharmacy will NOT call you if you skip the shipping option step.