Order Form | Rosemont Pharmacy

Vaginal Probiotic Patient Order Form

First Name *

Last Name *

Home Address:

Street*

City*

State*

Zip*

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)

Street

City

State

Zip

Email Address *

Contact Phone

Medication or Other Allergies (if none, please put 'none')

Date of Birth*

Compounded Vaginal Probiotic for Endometrial Receptivity

L. Rhamnosus + L. Gasseri Capsules ($4 per capsule) QTY:

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)

We want to make sure that your medication order is ready on time, to do so please indicate when you think you will you need your medications? *

Date Medication Needed if selected "By Date"

How do you plan to get your medications? *

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