Butalbital, Acetaminophen, and Caffeine (Generic Fioricet)

Name: Butalbital, Acetaminophen, and Caffeine (Generic Fioricet)
SKU: 1706
Availability: OutOfStock

Important Notice – Licensed States Only

Our pharmacy is currently licensed to accept patient intake forms, consultations, and prescriptions
only from residents of the following states:

Arizona • Colorado • Delaware • Florida • Hawaii • Idaho • Illinois • Maine • Missouri • New York • Ohio • Pennsylvania • Rhode Island • South Dakota • Utah • Washington • Wisconsin • Wyoming

If you do not reside in one of these states,
we cannot accept or process your medical intake form.

Please do not complete the form if you live outside these licensed states. Doing so will result in your submission being rejected.

We apologize for any inconvenience. We recommend consulting a pharmacy licensed in your state.

Young man placing his fingertips to his temples with his eyes closed, indicating a tension headache.

Fioricet combines acetaminophen (325 mg), butalbital (50 mg), and caffeine (40 mg) to effectively treat tension headaches. This multi-action formula helps relieve pain, reduce muscle tension, and provides mild sedation. For complete details, see the Fioricet monograph.

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This field is for validation purposes and should be left unchanged.

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Gender*

Email*

Phone*

Street Address*

Address Line 2

City*

State*

If you do not reside in one of these states, we cannot accept or process your medical intake form.

Zip Code

Please explain the specific medical reason for ordering this medication. The physician must know the exact nature of your medical problem in order to prescribe this medication. ( Primary reason for requesting medication)*

How long have you had these symptoms?*

Weeks

Months

Years

How often do you experience symptoms? (Frequency per month)*

Occasional (1-4)

Frequently (>5)

Other

If other, enter frequency*

How long does a typical symptom last?*

Hours

Days

Describe your typical headache pain (check all that apply)*

Throbbing / pulsating

One-sided / both sides

Nausea / vomiting

Sensitivity to light (photophobia)

Sensitivity to sound (phonophobia)

Aura (visual, sensory, or other) before headache

Worsened by physical activity

Neck pain / stiffness

List all medications you have tried for headaches (include OTC & prescription) Medication, Dose, How often, Helped? (Y/N), Side effects*

Current medical conditions (check all that apply)*

Liver disease / hepatitis

Kidney disease

Alcohol use disorder

Drug/alcohol dependence history

Depression / anxiety

Sleep apnea

COPD / breathing problems

Porphyria

Stomach ulcer

None

Are you taking any other medications (including OTC, vitamins, supplements)? If yes, please list all prescription and over-the-counter medications that you are currently taking and the length of time for each.*

Yes (Please specify in "other")

If yes, please list medications*

Do you have allergies?*

Yes (Please specify in "other")

If other, please list allergies*

Do you have any past medical and psychiatric conditions including any surgery or other procedures?*

Yes (Please specify in "other")

If other, please list procedures*

Do you drink alcohol?*

Never

Rarely

Weekly

Daily

Average drinks per day when you drink*

History of substance abuse / addiction (self or family)?*

Yes

Have you ever been prescribed Fioricet, Esgic, generic butalbital/APAP/caffeine, or similar medication?*

Yes

Is your current physician aware of your ordering of this medication?*

Yes

Which of the following medication are you looking to get?*

Butalbital-Acetaminophen-Caffeine 50-325-40mg (White)

Butalbital-Acetaminophen-Caffeine 50-325-40mg (Blue)

What is the quantity you are looking to get?*

60 tablets

90 tablets

120 tablets

180 tablets

How often do you take this medication?*

Once daily

Twice daily

Three times daily

When required or needed

Do you need refills?*

Yes

What is the name of your previous pharmacy?*

Consent and Attestation (Check all)*

I certify that the information above is true and complete.

I understand Fioricet contains butalbital (a barbiturate) and can be habit-forming.

I agree to use it only as prescribed and not to share it.

I confirm I reside in one of the listed states above and understand that a prescriber fee as well as shipping and handing charges will apply.

Patient Signature (Please type your full name for consent and attestation)*

Date*

MM slash DD slash YYYY

Our Price:

Price range: $60.00 through $180.00

Type

Quantity

Clear

Butalbital, Acetaminophen, and Caffeine (Generic Fioricet) quantity

"*" indicates required fields

Instagram

This field is for validation purposes and should be left unchanged.

Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Gender*

Email*

Phone*

Street Address*

Address Line 2

City*

State*

If you do not reside in one of these states, we cannot accept or process your medical intake form.

Zip Code

How long have you had these symptoms?*

Weeks

Months

Years

How often do you experience symptoms? (Frequency per month)*

Occasional (1-4)

Frequently (>5)

Other

If other, enter frequency*

How long does a typical symptom last?*

Hours

Days

Describe your typical headache pain (check all that apply)*

Throbbing / pulsating

One-sided / both sides

Nausea / vomiting

Sensitivity to light (photophobia)

Sensitivity to sound (phonophobia)

Aura (visual, sensory, or other) before headache

Worsened by physical activity

Neck pain / stiffness

List all medications you have tried for headaches (include OTC & prescription) Medication, Dose, How often, Helped? (Y/N), Side effects*

Current medical conditions (check all that apply)*

Liver disease / hepatitis

Kidney disease

Alcohol use disorder

Drug/alcohol dependence history

Depression / anxiety

Sleep apnea

COPD / breathing problems

Porphyria

Stomach ulcer

None

Yes (Please specify in "other")

If yes, please list medications*

Do you have allergies?*

Yes (Please specify in "other")

If other, please list allergies*

Do you have any past medical and psychiatric conditions including any surgery or other procedures?*

Yes (Please specify in "other")

If other, please list procedures*

Do you drink alcohol?*

Never

Rarely

Weekly

Daily

Average drinks per day when you drink*

History of substance abuse / addiction (self or family)?*

Yes

Have you ever been prescribed Fioricet, Esgic, generic butalbital/APAP/caffeine, or similar medication?*

Yes

Is your current physician aware of your ordering of this medication?*

Yes

Which of the following medication are you looking to get?*

Butalbital-Acetaminophen-Caffeine 50-325-40mg (White)

Butalbital-Acetaminophen-Caffeine 50-325-40mg (Blue)

What is the quantity you are looking to get?*

60 tablets

90 tablets

120 tablets

180 tablets

How often do you take this medication?*

Once daily

Twice daily

Three times daily

When required or needed

Do you need refills?*

Yes

What is the name of your previous pharmacy?*

Consent and Attestation (Check all)*

I certify that the information above is true and complete.

I understand Fioricet contains butalbital (a barbiturate) and can be habit-forming.

I agree to use it only as prescribed and not to share it.

I confirm I reside in one of the listed states above and understand that a prescriber fee as well as shipping and handing charges will apply.

Patient Signature (Please type your full name for consent and attestation)*

Date*

MM slash DD slash YYYY

Our Price:

Price range: $60.00 through $180.00

Type

Quantity

Clear

Butalbital, Acetaminophen, and Caffeine (Generic Fioricet) quantity