Women's Sexual Health Medications Interest Form

Women's Health Medications Interest Form

Skippack Pharmacy is committed to improving health and hair loss for both men and women by offering a variety of medications, including erectile dysfunction treatments and options for female sexual health, various hair loss remedies, as well as anti-aging products. We understand the importance of addressing these sensitive issues and are here to support our community with personalized, compassionate care. Our goal is to provide effective solutions that help enhance well-being and restore confidence for those in need.
Let's learn a little more about you.

We may know some of you, we may not know others but we'd love to know everyone who we have the opportunity to serve & thus need some information to get you started.
Patient status with Skippack Pharmacy*

I have used Skippack Pharmacy for prescriptionsI have used Skippack Pharmacy for vaccines or testingI am new to Skippack Pharmacy
How did you hear about us?*

My DoctorA Friend / Family Member / Referred by Another Patient on Weight LossSkippack Pharmacy EmailFacebookInstagramGoogleChatGPTNextdoorWebsiteA News Story (Fox29, NBC, ABC, CBS)Skippack Village (Post/Newsletter)A News Website (NP Now, PV Now, Wiss Now)I Am A Patient of Skippack PharmacyMy Pharmacy Told Me About YouOther
Patient's Name*

First NameLast Name
Gender*

FemaleMaleOther
Date of Birth*

MonthDayYear
Date
Patient Address (if you will be requesting the product be shipped to you, please ensure the address below is your mailing address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Preferably non-comcast.net email addresses as Comcast has been filtering our emails or sending them to spam. If it is a comcast.net email address & you sign up, if you see the THANK YOU page after submitting, thats the same information that would get emailed to you.
Cell Phone Number*

Area CodePhone Number
Please list any allergies to medications.
If none, leave blank and move on to the next question.
Do you have a provider who you can get a prescription from?*

Yes, I have a provider (doctor, physician assistant, nurse practitioner, etc.) who will prescribe this medication for me.No, I do not but I would like to connect with a telehealth provider to get a script. Skippack Pharmacy cannot prescribe; however has worked with telehealth providers like Physician 360 who we can refer you to.
Please list the name and city of the DOCTOR/PROVIDER who may prescribe this medication for you (if you will be using a telehealth provider & not sure, write TELEHEALTH)*
Please list any other medications you may be taking.
If none, leave blank & move on to the next question.
Please list any current medical conditions.
If none, leave blank & move on to the next question.
Select below IF you have any of the following medical history? If YES, please ensure the provider who is writing your prescription is aware of this. If NONE, skip to next question.

History of known serious hypersensitivity to any ingredients present in these medicationsHistory of explicit medical advice to refrain from sexual activityPregnant or breastfeedingHistory of genital herpesHistory of chronic vaginal infectionsHistory of serious heart conditionsHistory of cancer, consult with doctor prior to usePheochromocytomaHigh heart rateCongestive Heart FailureHigh Blood PressureImpaired Kidney Function
Let's talk about the medication.

The best part about choosing a local pharmacy is that you get to speak to someone you can trust, someone you can reach out to with any issues, someone who wants to see succeed in your goals to better health. This information will allow us to provide you better service and help you along your journey!
WOMEN: Which formulation are you interested in?

Sexual Health: Scream CreamSexual Health: Climax CreamSexual Health: Euphoria CreamHair Loss: Minoxidil 2% solutionAnti-Aging: NADvantage topical creamAnti-Aging: Nicotinamide Adenine Dinucleotide (NAD+) injectable
At this time, compounded medications are not covered by insurance. Most of the medications on this form are compounded medications. Are you willing to pay OUT OF POCKET (can use HSA card, credit card, etc.) Prices are transparent and there are no hidden fees.

YesNo, I would only like this medication processed through insurance (Do not move forward as unfortunately, we cannot process compounded medications through insurance).
Any other information you would like to add to help us help you?
If nothing, leave blank & move on to the last line.
I understand and acknowledge that by filling out this form, I authorize Skippack Pharmacy to provide me with next steps. I will receive an email or click the link on the thank you page for next steps and will move forward with the directions provided therein. I also understand that this product cannot be processed through my insurance & am okay paying out of pocket for it.
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Women's Health Medications Interest Form

Let's learn a little more about you.

Let's talk about the medication.