Create your prescription – Numbing Cream

Name*

First Last

Phone*

This is the Phone Number the Doctor will use to call you, if necessary. Please double check to make sure that it is correct.

Email*

Date of Birth*

Do you have a history of allergies, specifically any allergic reactions to local anesthetics such as lidocaine or tetracaine? Additionally, are there any other allergies you have that I should be aware of?

Do you currently have any medical conditions, particularly conditions related to the heart, liver, or kidneys? Additionally, is there any other medical information you think is important for me to know?

Are you presently taking any medications, including over-the-counter drugs and herbal supplements? If so, please provide details about the medications you are currently using

Are you currently pregnant, planning to become pregnant, or breastfeeding? Please provide information regarding your current pregnancy or breastfeeding status

you have any existing skin conditions or open wounds in the area where the cream will be applied? Please provide details about the condition of your skin in the intended application area

What symptoms are you experiencing, or what is the purpose for using the anesthetic cream? Please provide details about the specific reasons you are considering the use of the cream

Have you used topical anesthetics before, and if yes, did you experience any side effects or reactions? Please provide details about any previous experiences with topical anesthetics

Numbing Cream

Price: $ 46.50

Numbing Cream

Price: $ 1.00

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Coupon

Total

(If physician does not approve, this amount will be fully refunded.)

Height*

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Weight (lbs)*

Sex*

Male

Female

Past Medical and Surgical History*

Allergies*

BILLING ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Billing Address Same as Shipping Address?*

YES

NO

SHIPPING ADDRESS*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I agree to medinumbsolutions Terms and Conditions*

I Agree

PRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)**

First Last

Signature*

Date SIGNED (mm/dd/yyyy):**

Total

(If physician does not approve, this amount will be fully refunded.)

Credit Card*

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ONE-TIME ORDER*

ONE-TIME ORDER ONLY

You can choose to make this order a one-time order or plan to get it delivered every month. (If you are choosing to have recurring orders of Semaglutide, you are agreeing to a tiered dosing schedule with price increases monthly.)

This form will be sent to our Physician for review and issuing prescriptions for your order

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