To begin ordering, you must fill out the below information. Please fill in all of the required areas in blue text. No order can be filled without the completion of this order form. You must be at least 18 years of age to begin treatment. Always consult with your doctor before taking any new treatment. If you have any questions, please call us at: 1-800-511-5706 Monday thru Friday from: 9am to 4pm EST.
ClearMed Order Form
*Please choose your treatment and quantity below:                  Quantity:
      *First Name:                                              *Last Name:                                 *Date of Birth:
*Address:                                                                       *City                            *State
  *Zip  Code                                                                      *Mobile/Home Telephone
*E-mail Address                              
*Please ship to this address above?
If no, please provide address below:
**Important: Please fill in a valid e-mail address. Please verify spelling. This is where we will send your tracking# and
any receipts.
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Your Health Condition
How long have you had your hemorrhoid condition?




Would you consider your condition severe?


Have you ever seen a doctor for your condition?


Are you taking any medications for your hemorrhoid condition?

If yes, please describe below:
Do you have any other health issues other than hemorrhoids?:
If yes, please describe below:
Do you take any other medications for other health issues?:
If yes, please describe below:

*Once you submit this form, a payment link will be e-mailed to you. All orders are shipped by Express due to the urgency in most cases. If you ever have any questions, please call our center at: 1-800-511-5706 Monday thru Friday from: 9am to 4pm EST.
YesNo
recent occurrence  under 1 yearon and offmany years
yesno
yesno
yesno
yesno
yesno