Cost-Plus Pharmacy. No Insurance Required.

Cart

“Anti-Inflammatory Tea” has been added to your cart. Continue shopping

Remove item	Product	Price	Quantity	Subtotal
	DR JART Dermask Cicapair Calming Sheet Mask	$7.00	DR JART Dermask Cicapair Calming Sheet Mask quantity	$7.00
	Anti-Inflammatory Tea	$23.00	Anti-Inflammatory Tea quantity	$23.00
Coupon:

Cart totals

Subtotal	$30.00
Total	$30.00

FIrst Name

Last Name

Date of Birth

Gender

Height (inches)

Weight (lbs)

Your Phone

Preferred Method of Contact

Address

Are you filling a medication for your pet?

Pet name*

Date of birth:

Species type:

Allergies: (enter n/a if not applicable) - include name of patient

Taking any medications, currently?

Yes - for me No - for me Yes - for pet No - for pet

If yes, Please list all medications here (include name of patient)

Prescriptions:

Please select all that apply:

Previous/Current Pharmacy Contact Information

In case of emergency:

First Name

Last Name

Relationship

Contact Number