Vaginal Probiotic Patient Order Form

Home Address:

Shipping Address:

(Free Ground Shipping for M-F *overnight fees may apply)

Shipping address is the same as home address.

(If selected do not fill in Shipping Address)

Compounded Vaginal Probiotic for Endometrial Receptivity

I plan to use under separate direction of my physician.
I plan to use under pharmacy recommendation for embryo transfer:(Insert 1 probiotic vaginally for 7 days, ending the day prior to transfer. Qty: 7)

  Once this form is received, Rosemont Pharmacy will contact you regarding payment. If you have any questions, or would like Rosemont Pharmacy to assist you, please contact us at (610) 525-3570