Pharmacy Order -

Pharmacy Name

Person Placing Order

Your Email

What kind of order are you needing?

Pharmacy Order Quote Only

% Diclofenac in PLO Gel

% Diclofenac in Versapro Cream

% Diclofenac

% Cyclobenzaprine

% Gabapentin

% Lidocaine

% Menthol

Select Base

PLO OR MEDIFLO VERSAPRO LIPO BASE OTHERS (Kindly specify in notes)

Base Details

Quantity (GM)

Pharmacist License Number

Other Compounds Not Listed Above

+1.780.243.3546