Intake Form

Intake Form

Complete this secure, HIPAA-compliant form to begin your personalized medication journey with CoveRx. Your responses will help our licensed healthcare providers create your patient profile, determine eligibility for treatment, and initiate your subscription-based care plan. Once submitted, you’ll receive an invitation to your CoveRx Patient Portal to complete onboarding and schedule any necessary follow-up. Please ensure all information is accurate to avoid delays in processing your intake.
What is your first and last name?*

First NameLast Name
What is your date of birth?*

MonthDayYear
Date
What is your gender?*

MaleFemaleNon-binaryTransgender maleTransgender femalePrefer not to sayOther (please specify)
Phone Number*
Please enter a valid phone number.
Email address?*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What are you interested in today? (Select all that apply)*

Weight LossAttention DeficitHormone & Sexual HealthMental HealthCardiovascular & Metabolic HealthOther (please specify)
Do you have any of the following conditions?:
Weightloss:

Type 2 diabetesPre-diabetes / insulin resistanceMetabolic syndromeSleep apneaPolycystic ovary syndrome (PCOS)Gallbladder diseaseHypothyroidismHistory of bariatric surgeryNon-alcoholic fatty liver disease (NAFLD)None of the above
Attention Deficit:

History of seizuresHeart diseaseHigh blood pressure (hypertension)Irregular heartbeat (arrhythmia)Structural heart defectsGlaucomaAnxiety disorderNone of the above
Hormone & Sexual Health:

MenopauseLow testosterone / hypogonadismOsteoporosisErectile dysfunctionPolycystic ovary syndrome (PCOS)Certain types of cancer (breast, colon, endometrial, prostate)Chronic kidney diseaseHistory of blood clots or clotting disordersNone of the above
Mental Health:

DepressionAnxietyBipolar disorderSchizophrenia or other psychotic disordersPost-traumatic stress disorder (PTSD)None of the above
Cardiovascular & Metabolic:

High blood pressure (hypertension)High cholesterolHeart diseaseStrokePeripheral artery disease (PAD)Chronic kidney diseaseObesityGastroesophageal reflux disease (GERD)None of the above
Do you currently take any medications?*

YesNo
If yes, please list:
Do you have any known allergies to food or medication?*

YesNo
If Yes, please specify any foods or medications you are allergic to:
You’re selecting a preferred appointment time. We’ll finalize your appointment after your intake is complete and notify you through the patient portal. Make sure to book in your correct time zone. Use the time zone switcher at the bottom of the calendar.*
Important to Know:

The date and time you select is your preferred appointment slot.

Your final consultation will be scheduled after your intake and onboarding steps are complete.

Once your forms are submitted, our team will review your information, confirm your eligibility, and follow up with appointment options via your patient portal (an invite will follow-up within 24 hours).
You’ll have time to confidently ask questions and finalize your care plan.
Should be Empty:

Intake Form

Do you have any of the following conditions?: