1670 ROUTE 34 N. 3R FLOOR SUITE 3C WALL • NJ 07727

Covid-19 Form

Are you currently sick and showing symptoms of COVID-19? *

When did your first symptoms begin? *

Are you looking to obtain Invermectin for prophylaxis?
In other words, are you currently well, but want to have Invermectin to prevent getting COVID-19? *

Are you taking any of these medications? *

Are you taking any medications or supplements for COVID-19?
Choose as many as you like

What is your weight? * (ex. 175 lb)

Are you currently pregnant, suspect that you may be pregnant, or breastfeeding?

What is your full name? *

Date of birth *

What is your best contact phone number? * (only numbers)

What City or Area are you located in? *

What is your e-mail address? *

ABOUT

FOR PATIENTS

SERVICES

HOLISTIC MEDICINE

CONTACT US

Hours :

Monday- 9:30 AM to 4 PM
Tuesday - 9:30 AM to 6 PM
Wednesday - 9:30 AM to 4 PM
Thursday - 9:30 AM to 5 PM
Friday - 9:30 AM to 4 PM
Sat-Sun: Closed

Disclaimer: The information provided on this site is for educational purposes only and does not substitute for professional medical advice. Please consult a medical professional or healthcare provider for medical advice, diagnoses, or treatment. If you are experiencing a medical emergency, dial 911.

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1670 ROUTE 34 N. 3R FLOOR SUITE 3C WALL • NJ 07727

+1 732 268-7663

1670 ROUTE 34 N. 3R FLOOR SUITE 3C WALL • NJ 07727

+1 732 268-7663

Covid-19 Form

ABOUT

FOR PATIENTS

SERVICES

HOLISTIC MEDICINE

WEIGHT-LOSS

CONTACT US

Hours :

FOLLOW US