Prescription Medication Request
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Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Preferred email address
*
example@example.com
Requested Pharmacy:
*
Same as last time
Other
Requested Medication(s):
*
Same as last time
Other
Any Medication Side Effects?
*
None at all
Yes, but they're mild and tolerable, I'm not worried
Yes, they're severe, I'm worried, and I need to speak with a provider right away
Please feel free to share anything that might help us better complete your request.
Signature and agreement to terms, conditions, privacy and Telehealth policies:
*
Complete Payment:
*
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Prescription Service
48 hour service completion guaranteed. Monday through Friday. For established patients only.
$
99.99
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
How are we doing?
I LOVE it here
It's okay
This place is the worst
Other
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