CHS Patient Intake Form

Patient Intake Form

Tell us about you.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Sex*
Height (inches)*
Weight (lbs)*
Phone Number:*
Email*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you refilling a prescription?

YesNo
Medical Information

Answer the questions below and provide any details as needed.
Do you have a fever?*

YesNo
Do you currently have any specific symptoms.*

YesNo
Please list any specific symptoms here:
Are you currently taking any medications?*

YesNo
Please list all the medications here:
Are you taking any medicines, supplements, herbal remedies, or other prescriptions?*

YesNo
Please list them all here:
Do you have any additional medical information you wish to add or questions?*

YesNo
Please add it here or type in your question:
Pharmacy Details

Select the pharmacy where you'd like to pick up your prescription. Ensure the pharmacy details - name, address, zip code, and phone number are accurate.
Name*

Pharmacy NamePharmacy Phone Number
Pharmacy Address*

Street

Street Address Line 2

CityState / Province

Postal / Zip Code
We typically prescribe affordable, generic treatments unless you choose otherwise. If the medication cost is too high, ask your pharmacist about cheaper alternatives or options covered by your insurance.
Select Your Prescription

Medical conditions are organized within two option. Select your medical condition below.
Select your prescriptions below.
Categories:All

All

1. General Health Conditions

2. Sexual Health and Well-Being
prevnext( X )
1. General Health Conditions

Acne (Women)
$39.99 Quantity



Cold Sore
$39.99 Quantity



Dental Infection
$39.99 Quantity



Ear Infection
$39.99 Quantity



Genital Warts
$39.99



Jock Itch
$39.99



Oral Thrush
$39.99



Pink Eye
$39.99



Sick Note For Treatment
$29.99



Sinus Infection
$39.99



Strep Throat
$39.99



Stye
$39.99



Syphilis
$69.99



Upper Respiratory Infection (URI)
$39.99



Urinary Tract Infection (UTI)
$39.99



2. Sexual Health and Well-Being

Bacterial Vaginosis
$39.99



Chlamydia
$39.99



Chlamydia & Gonorrhea
$59.99



Erectile Dysfunction
$59.99



Genital Herpes
$39.99



Gonorrhea
$39.99



Mycoplasma Treatment
$59.99



Trichomoniasis
$39.99



Trichomoniasis, Chlamydia & Gonorrhea
$69.99



Urethritis
$59.99



Yeast Infection
$39.99



Total

$0.00
I am aware that:*

I have a full refund option at any point before my prescription are sent in. Once a medical professional has finished your treatment plan and sent your prescription to your pharmacy or completed your request, our fee is no longer refundable.Every effort to complete all consultations within two hours. However, insufficient medical data, technical issues, or a high patient volume may cause the turnaround time to be prolonged. Be prompt if you must cancel due to delays. If your request for a refund is made after we have sent your prescription to the pharmacy or finished the treatment plan, the fee is NOT refundable.The cost is non-refundable in the event that my body does not respond to treatment or if the prescribed medicine does not entirely cure my condition or eliminate all of my symptoms. You are welcome to submit a second form for review.
Should be Empty:

Patient Intake Form

Medical Information

Pharmacy Details

Select Your Prescription