Step 1 of 4 25% HiddenPharmacy(Required) Agent/Rep(Required)Not SelectedAgent 1Agent 2Agent 3HiddenDate MM slash DD slash YYYY First Name(Required) Last Name(Required) Gender(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY Phone(Required)Email Basic InfoStreet Address(Required) Apartment/Unit Number (Leave Blank if N/A) City(Required) State(Required)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code(Required) Country(Required)AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsSocial Security Number (Last 4 at least)(Required) Insurance InfoCurrent Health Insurance Carrier(Required)United HealthcareHumanaCignaSuperiorAmerigroupWellcareBlue Cross/Blue ShieldOther - Type in "Notes" section belowMember ID RxBIN RxPCN RxGRP Treatment Areas Requested Pain Scar Rash/Irritation Anti-Fungal Acid Reflux/GERD Muscle Spasms/Tightness Inflammation Seasonal Allergies Multi-Vitamin Cold Sores Acne/Rosacea Probiotic Migraine GOUT What is/are the location/locations of your pain? When was the onset of pain? What was the cause of pain? What is the duration of pain?Not RequestedDailyTime to TimeActivity ActivatedConstantCan you describe the pain?Not RequestedSharp/StabbingDull AcheThrobbing/PulsatingStiffness/TightnessWeak Feeling/UnstableRadiating/TravellingPins & NeedlesWhat makes your pain feel better?Not RequestedHeatIceLying DownRestHot ShowerMedicationCould you please rate your pain on a scale of 1-10? 10 being the worst.Not Requested12345678910What is the cause of your scar?Not RequestedAccident/InjurySurgeryEczemaPsoriasisHave you treated the scar before?Not RequestedNoYes, with creamYes, with plastic surgeryYes, with over the counter productsWhere is your scar/scars located? How long have you had this scar? Where is your rash/skin irritation located? How long have you had this rash/skin irritation? What is the cause of your rash/skin irritation? Have you treated the rash/skin irritation before? If yes, how? Where is the fungal issue located? How long have you had this fungal issue? Have you previously treated the fungal issue? If yes, how? How often do you experience heartburn/acid reflux/GERD?Not RequestedNever1-3 times per week4-6 times per weekDailyConstantWhat do you do to relieve your heartburn/acid reflux/GERD?Not RequestedDiet ChangeOver the counter medicationPrescribed medicationRestHow long have you experienced muscle spasms or muscle tightness? What have you done to treat your muscle spasms in the past? Would you be interested in an oral muscle relaxant if the physician deems you a good candidate for this treatment option?Not RequestedYesNoWith regards to the pain you indicated, do you experience muscle or joint inflammation in any area/s? If yes, which area/s? How long have you experienced inflammation? What have you done to treat inflammation in the past? Would you be interested in an oral non-steroidal anti-inflammatory product if the physician deems you a good candidate for this treatment option?Not RequestedYesNoHow long have you exhibited symptoms of seasonal allergies? What symptoms of seasonal allergies do you experience? Would you be interested in an anti-histamine if the physician deems you a good candidate for this treatment option?Not RequestedYesNoAre you currently taking an antihistamine?Not RequestedYesNoAre you generally feeling sluggish or lacking energy at any point in your day?Not RequestedYesNoDo you often get sick with the cold or flu?Not RequestedYesNoHow often do you experience cold sores?Not RequestedDailyWeeklyMonthlyYearlyNeverDo you have a cold sore now?Not RequestedYesNoHave you ever had Acne before?Not RequestedYesNoDo you have Acne or Rosacea currently?Not RequestedYesNoWhere is your acne/rosacea located? How long have you had acne/rosacea? Have you treated your acne/rosacea? If yes, how? Have you ever experienced a migraine?Not RequestedYesNoHow often do you experience migraines?Not RequestedDailyWeeklyMonthlyNever Are you allergic to any medications? If yes, please list here. Please list all current medications that you are taking as well as dosages.Please list all current major health conditions and diagnosis or any other information that the doctor may need to know. Try to include dates of diagnosis if possible.If you take any Over the Counter medications, please list them here.Systolic (mmHg) Diastolic (mmHg) Closing StatementsDo you consent for Telehealth doctor consultation?(Required)YesNoDo you consent to Auto Shipment?(Required)YesNoDo you consent to Auto Refill Option?(Required)YesNoDo you consent to Copay Disclosure, if any?(Required)YesNoDo you consent to TCPA contact?(Required)YesNo
