Pharmacy meds

This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.

For assistance with forms call us at (281) 393-8266
Patient History
Please enter your first and last name as it appears on your ID or DL:*

First NameLast Name
Date of birth: MM/DD/YYYY*

MonthDayYear
Date of Birth
Please confirm your best email address:*
example@example.com
Please enter your phone number:*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your shipping address the same as above?*

YesNo
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter your current weight for proper medication dosing:*
Lbs
In order to legally establish a doctor-patient relationship online, please upload a current photo of yourself to help verify your age and identity.
We deeply respect your privacy and wouldn’t ask except that it’s required by law (have to weed out any little kids trying to trick us!). Please upload a photo of you alone (aka a selfie); do not include anyone else in the image. If you send us a photo of you with your kids or your wife/husband, we will have to ask you to send us a new photo. We never share your files with anyone. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.
Upload File

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Take Photo
To match the photo of yourself please upload a picture of your photo ID with your name and date of birth. Our systems are designed to protect you from identity theft, so you can hide your license number and any other sensitive information if you want to. Your photo, name, and date of birth are the ONLY fields that must be visible on the picture. Please double-check that the photo isn't blurry.
Using your phone's camera or scanning an image of your ID is usually preferable; however, please avoid using a webcam because the image quality will prevent you from seeing the text on your ID.

This is in order to protect you from someone requesting meds in your name and to protect us from treating the wrong person. I drop this in our encrypted vault and never share your photos or data with anyone.
Upload File

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Take Photo
I am unable to attach files.
Please select the reason(s) you are unable to upload your file(s):*

I do not have access to the files right nowThe upload links aren't working for meI can't find the files on my device when I click the upload linkThe upload link won't accept my file types.
You can share the documents via our secure patient portal or please email us the required documents at prescriptions@mygotodoc.
Please enter your most CURRENT weight and ACTUAL height, without shoes, for our records and for proper medication dosing (this does NOT need to match what is shown on your ID)*
What is your gender?*
In Pregnancy: AVOID ivermectin and fluvoxamine. While Breastfeeding: AVOID fluvoxamine ivermectin is probably safe (as observed).*

I acknowledge that I have received the above warning on pregnancy and breastfeeding

TURTLE HEALING BAND MEMBERSHIP AGREEMENT*
Patient Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
I do hereby request membership in Turtle Healing Band (“THB”) to be treated as a patient by a Tribal Provider (“TP”) licensedand approved by First Nation Medical Board (“FNMB”). With the signing of this Agreement, I/we agree that all people have a divinely-given right to choose and receive for themselves any type of healing they feel is best for their mind, body and spirit. These options include, but are not limited to, all forms of indigenous medicine (e.g., alternative, complementary, holistic, integrative, etc.) whether traditional or non-traditional, as well as conventional medicine.

In addition, I affirm and understand that: (1) THB members are protected by the First and Fourteenth Amendments to the U.S. Constitution as well as the United Nations General Assembly (Universal Declaration of Human Rights adopted at the Palais de Chailot in Paris on December 10, 1948); (2) THB is outside the jurisdiction and authority of federal, state, county, and city agencies and authorities for any and all complaints or grievances against FNMB, FNMB licensees, FNMB staff, Turtle Healing Band Clinics (“THBC”), and THBC staff; and (3) THB member records are the private property of THBClicensed facilities and are kept confidential.

I also swear under penalty of perjury that I am here solely on my behalf and not as an agent or representative for any Federal, State, County, or City Agencies, that I neither represent any Board (e.g., medical, zoning, etc.) or Licensing Agency (e.g., government, healthcare, etc.) nor am I on a mission of entrapment or investigation on behalf of these or any otheragencies, either on this or any subsequent visit(s), and I agree to pay $250,000.00 (Two Hundred Fifty Thousand Dollars and No Cents) in liquidate damages if I am found to be in violation of this covenant.
Initials*
UNDERSTANDING

I (and my family) agree to become a patient(s) and private member(s) of THB so that I/we may be entitled to receive goods and services from a TP providing service in a THBC facility. I/We further understand that it is entirely my/our own responsibility to consider the advice and recommendations offered to me/us by TPs or our fellow THB members and to educate myself/ourselves as to the possible risks and benefits of such recommendations. I/We agree to hold the tribal practitioners, healers, technicians, staff, and other THB members harmless from unintentional liability resulting from my/our indigenous healthcare, except for harm that results from criminal misconduct or gross negligence as determined by FNMB and/or defined by Crow Tribal Court. I/We hereby submit myself/ourselves to the jurisdiction of FNMB for the referral of any and all professional complaints against TPs and to submit such complaints to FNMB for dispute resolution. Further, I/We agree to submit any civil complaints against TPs to Crow Tribal Court for dispute resolution.
Initials*
NOTICE

Notice is hereby given to all persons that they may be in violation of Civil and Constitutional Rights should they receive a copy of this Agreement and then act under the color of law to intentionally interfere with the free exercise of the Rights retained by THB members under the Ninth Amendment (see Title 42, U.S.C 1983 et seq.; see also Title 18, Sec 241-42).

ANNUAL FEES
- $35.00 (Member)
- $15.00 (Member’s Spouse)
- Free (Children)
I enclose the fees required as consideration for my/our membership affiliation and agreement. I agree to pay these fees yearly, unless otherwise instructed. The term of my/our membership begins with the date of the signing of this agreement. I hereby certify, attest and warrant that I have carefully read the above and foregoing THB membership agreement and I (and my family) fully understand and agree with its terms and conditions.
Member Signature*

Clear
Date*

MonthDayYear
Date
Spouse Signature*

Clear
Date*

MonthDayYear
Date
CHILDREN
(name, age, gender)
1.*
2.*
3.*
4.*
*First Nation Medical Board (“FNMB”) d/b/a Turtle Healing Band is authorized by agreement with Crow Nation to create a Tribal Health Care Program that licenses Tribal Providers of indigenous medicine to provide indigenous healthcare services for its private THB members. Tribal Providers include allopaths (MDs), osteopaths (DOs), chiropractors (DCs), naturopaths (NDs), homeopaths (HMDs), and other healing arts (i.e., nurses, massage therapists, colontherapists, etc.). Private membership includes indigenous medicine patients, members of the Crow Nation, and Crow Nation affiliates.

Telehealth Service Waiver and Limitation of Liability

By using our telehealth services, you acknowledge and agree to the following terms and conditions:

1. Scope of Service: Our telehealth consultation provides medical advice and treatment based on the information you provide during your consultation. Our medical responsibilities end once your prescription is issued or a treatment plan is provided. We are not your primary care provider (PCP), nor do we assume any ongoing responsibility for your medical care.

2. No Follow-Up: We are not obligated to follow up, call, or message you to check on your condition or progress after your consultation. It is your responsibility to seek further medical care if your condition does not improve or worsen or if you experience new or unexpected symptoms.

3. Emergency Care: If you feel that your condition is not improving or experiencing a medical emergency, you must seek immediate care at an emergency room (ER) or urgent care facility. Telehealth is not a substitute for in-person medical services, particularly in emergencies.

4. Limitations of Telehealth: Our services are limited by the nature of telemedicine. We cannot perform physical examinations, laboratory tests, or imaging, which may be necessary for diagnosing or treating certain conditions. Therefore, you agree to seek in-person medical care as needed.

5. Complications and Risks: By accepting the services, you understand that we are not responsible for any possible complications, adverse reactions, or outcomes from the prescribed treatment. All medical treatments carry risks, and it is your responsibility to monitor your condition and seek further medical attention as necessary.

6. No Ongoing Doctor-Patient Relationship: The telehealth consultation and the issuance of a prescription do not establish a long-term doctor-patient relationship. This consultation is a one-time service, and we do not assume any ongoing responsibility for your healthcare after the consultation.

7. Patient Responsibility: It is your responsibility to follow the treatment plan provided and to seek further medical care if your condition does not improve or if you experience any side effects. Our telehealth service does not include ongoing monitoring, and we will not be responsible for managing any future health concerns.

By using our telehealth service, you acknowledge that you understand and agree to these terms.
Patient Acknowledgment*

I have read and understand the above terms and conditions, and I agree to abide by them. I acknowledge that I am responsible for seeking additional medical care when necessary and that this telehealth consultation is a limited one-time service.

Medical Review and Prescription Eligibility Warning
Please note that your medical chart and the information provided will be meticulously reviewed by our medical team to determine your eligibility for the requested medications. Based on this review, the medical team reserves the right to deny the prescription if deemed appropriate for your health and safety. If your prescription request is denied, you will be entitled to a complete refund of any fees paid for the medication request. Our priority is to ensure that any medication prescribed is in the best interest of your health and well-being.*

Yes I Understand
Note: Once an order has been processed, we are unable to accept any returns, and all sales are considered final.

Estimated Delivery Time : Upto 2 Weeks
Should be Empty:

Patient History

Medical History

Medical Review and Prescription Eligibility Warning