Cash Pay Prescriptions CA Facebook Lead RX Simple

Patient Intake Form

HIPAA-Compliant Form. Securely submit your information below.
Name*

First NameLast Name
Date of Birth*

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Select Your Prescription

Prescriptions are organized below. You can choose just one or select multiple if needed. The total cost will update automatically.
Categories:All

All

1. General Health Conditions

2. Chronic Medical Conditions

3. Sexual Health and Well-Being

4. Prescription Refill
prevnext( X )
1. General Health Conditions

Acne (Women)
$39.99



Back Pain
$39.99



Cold Sore
$39.99



Dental Infection
$39.99



Ear Infection
$39.99



Headache/Migraine (Without red flags)
$39.99



Jock Itch
$39.99



Pink Eye
$39.99



Sinus Infection
$39.99



Strep Throat
$39.99



Stye
$39.99



Upper Respiratory Infection (URI)
$39.99



Urinary Tract Infection (UTI)
$39.99



Nausea Vomiting
$39.99



Sick Note For Treatment
$29.99



Other
$39.99



2. Chronic Medical Conditions

Acid Reflux (GERD)
$39.99



Anxiety
$39.99



Asthma
$39.99



Cerebrovascular Disease (Stroke)
$39.99



Chronic Kidney Disease (CKD)
$39.99



Chronic Obstructive Pulmonary Disease (COPD)
$39.99



Depression
$39.99



Diabetes Mellitus
$39.99



Fibromyalgia
$39.99



Heart Disease (Coronary Artery Disease, Heart Failure, A. fib)
$39.99



Hyperlipidemia (High Cholesterol)
$39.99



Hypertension (High Blood Pressure)
$39.99



Muscle spasm
$39.99



Neuropathy
$39.99



Thyroid Disease
$39.99



Other
$39.99



3. Sexual Health and Well-Being

Bacterial Vaginosis
$39.99



Cold Sores
$39.99



Erectile Dysfunction
$39.99



Genital Herpes
$39.99



Gonorrhea, Chlamydia, & Trichomoniasis
$39.99



Premature Ejaculation
$39.99



Vaginal or Penile Discharge
$39.99



Yeast Infection
$39.99



Other
$39.99



4. Prescription Refill

Prescription Refill
$39.99



Total

$0.00
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:
Do you have any allergies?
Do you have any existing medical conditions?
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
Would you like to notify your primary care physician that you are being prescribed these medications? If so, please leave their name and contact information.
Physician Name, Email or Phone Number
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.
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

Select Your Prescription

Medical Information

Pharmacy Details