Request Care in 4 Easy Steps

Please complete the form below to request care from a licensed medical provider. This information is used by the medical provider to review your request and provide a care recommendation.

1. Choose Pharmacy

Search your Zip Code or city to find a pharmacy.

Retail / Store Pickup

2. Patient Information

First Name

Last Name

Sex

Male Female

Date of Birth

Phone

Address(Line1)

Address(Line2)

City

State

Zip Code

3. Patient Health Information

Past Medical Problems (e.g. Asthma - if none, type "none")

Current Medications (if none, type "none")

Known Allergies (if none, type "none")

Are you pregnant?

Are you breastfeeding?

Yes No

Condition

Do you have any symptoms? (tell us more about how you feel)

If needed, are you able to follow-up with a doctor?*

4. Confirm Request and Agree to Terms

I agree to provide more information about my health if requested by the provider. After you submit your request, a licensed medical provider in your area will review your information.

I agree to the Terms and Conditions and Consent to Telehealth.

By clicking the "Submit Request" button below, you indicate that you, as the patient or legal guardian of the patient agree to the Terms and Conditions and Consent to Telehealth.


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