Bay Pharmacy Discount

Consultations

Have any concerns about your medicines? Pharmacists are among the most qualified to help you with this matter. You can schedule a consultation with one of our pharmacists by filling out the form provided.

Who is this prescription for? (* = Requiered Information )

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Who is this prescription for? (* = Requiered Information )

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* = Requiered Information

Full Name *

Address*

City *

State*

Zip*

How do you prefer to be contacted?

Email Address*

FAX

Phone *

Best time to call *

Preferred Date

Preferred DateCurrent Medical ConditionsDo you take any Food/Vitamin supplements? If so, what?Do you smoke? If yes, how many per day?Exercise (what types and how often)

How well do you sleep?

GoodAverageRestlessPoor

Average hours of sleep per night

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