Custom Care Shop

First Name*

Last Name*

Phone*

Email*

Are you ordering a troche?*

Please select your preferred flavour*

Do you have any allergies?*

Please list any known allergies

Are you currently taking any medications or supplements?*

Please list your medications below*

Please list your supplements below*

Do you have any current or past health conditions?*

Please select any that apply or specify other*

Please specify your medical conditions*

Are you pregnant?*

Are you breastfeeding?*

Do you have your prescription available to upload?*

Please upload a copy of your prescription*

Online Compound Medicine Order Form