International Medical Access Program

International Medicine Access Program

Telemedicine services provided under and by foreign medical practitioners
General Information
Full Name

First NameLast Name
Birth Date

MonthDayYear
Shipping Address

Street Address or Box Number

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
example@example.com
Phone Number

Country CodeArea CodePhone Number
Gender
Medical History
Are you under the care of a qualified healthcare professional? Please list whom.
I acknowledge that I will remain under the care of a local healthcare professional who will continue to monitor any medications I take and any health concerns that i have.
What medications, supplements and over the counter items do you take regularly or are currently prescribed:
Any past surgeries and hospitalizations?
Please list any/all allergies

Health History

Rows	No, never	Yes, currently	Not currently, but within the last year	Not currently and longer than 1 year ago
Fatigue
Depressive symptoms
Anxiety
Thyroid problems
Diabetes
Blood sugar irregularities
Headache
Joint pain or stiffness
Muscle weakness or soreness
High blood pressure
Heart murmur/palpitations
Cold or pale extremities
Asthma
Constipation
Diarrhea
Liver problems
Kidney problems
Irregular Heartbeat
Are you pregnant/breastfeeding
Epilepsy / Seizures
Cancer

Any additional Health History information or explanation you would like to provide?
Medicine Requested
Medicine (s) requested - check all that apply

Other
Quantity of Hydroxychloroquine 200mg requested to be sent through InsulinHub.com portal. Capsules may also be emptied into food/water for those who have trouble swallowing tablets. We have both brand Plaquenil and the generic version currently at the same price.
Quantity of Azithromycin requested to be sent through InsulinHub.com portal
Quantity of Ivermectin + doxycyline 100mg requested to be sent through InsulinHub.com portal
Quantity of Nitazoxanide 500mg requested to be sent through InsulinHub.com portal
Quantity of Budesonide nebules 1mg/2ml requested to be sent through InsulinHub.com portal
Quantity of Budesonide 200mcg inhalers requested to be sent through InsulinHub.com portal
Quantity of Colchicine 0.5mg requested to be sent through InsulinHub.com portal
Quantity of Rocaltrol (calcitriol) 0.25mcg by Roche requested to be sent through InsulinHub.com portal
Naltrexone Low Dose
Describe fully the name, strength, and directions of use for the "other" medicine requested
I understand that these medicines are manufactured in India an will be shipped directly from India. I also accept that shipping times will take an average of 2 to 3 weeks with the present coronavirus delays.
For what purpose do you request this medicine?
I understand that InsulinHub.com is given full permission to this form immediately and will confirm my order prior to the final consent of the physician. I understand that my order may be cancelled at the discretion of the physician prior to shipping and an agent assigned by the physician will contact me if this is the case.
I hereby confirm that all questions were answered accurately and I hold harmless all medical providers approving or not approving a prescription. I have approached this medical provider myself as if personally in his office in the country of his practice, requesting a specific medication for the purpose given. I will not take the medicine itself unless I am advised by a local physician directly. I also hold harmless the pharmacy and website platform by which I found this medicine and am completing this order. I take full personal responsibility for my decision to consult with a foreign physician and to receive this medicine from that same jurisdiction.
My preference for payment (Visa/MC)
How did you hear about us?
Be as specific as possible
Should be Empty:

International Medicine Access Program

General Information

Medical History

Medicine Requested