PHO Pre-Screening Form

Pre-Screening

Welcome PharmXHealthOne Online Clinic! We’re so glad you’re here , where your health and well-being come first!
What to Expect
This medical intake process helps ensure your care is safe, appropriate, and provider‑led.
- You’ll complete a brief medical pre‑screening to help route your care
- New patients complete a one‑time registration and upload a photo ID, similar to an in‑office visit
- You’ll complete an online consultation and upload photos of your current medications (labels visible)
- In some cases, your provider may request recent or new bloodwork to meet medical guidelines and ensure your safety. If needed, our team will guide you through the next steps.
- For weight loss treatments only, a full‑body selfie is required to help confirm weight and eligibility
- A licensed medical provider reviews all submitted information
- You will not be charged for treatment unless your order is reviewed and approved
Date*

MonthDayYear
Date
Patient Status*

NewCurrent
How did you hear about us?*
Name*

First NameMiddle NameLast Name
E-mail*
example@example.com
Phone Number*
Birth Date*

MonthDayYear
HEALTH PACKAGE*

Weight Loss EssentialsWeight Loss ResetMaintain WeightHormone BalanceEnergy and Vitality BoostPerformance and Lean MuscleSexual Wellness and Libido SupportImmune Boost and ResilienceAnti-Aging and LongevitySkin Health and GlowBlood Sugar and A1C Control (Diabetes)Inflammation RecoveryFull Body DetoxNutrition Deficiency SupportGeneral Wellness and Preventive CareExosome TherapyCognitive Vitality SeriesGut Restoration & Resilience SeriesPerformance & Recovery Optimization Serie
✨ New! Flexible Financing Now Available ✨
Get the care you need today and pay over time with Affirm & Afterpay. Ask our staff to learn more.
You’re on the right track.
Next, you’ll complete required registration and consultation details so a licensed provider can safely review your request.

Some information may repeat to meet medical and pharmacy requirements.

Questions? Contact us at health@pharmxhealthone.com or (561) 778-8121. We look forward to supporting your health journey!
Please verify that you are human*
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Pre-Screening

✨ New! Flexible Financing Now Available ✨Get the care you need today and pay over time with Affirm & Afterpay. Ask our staff to learn more.

✨ New! Flexible Financing Now Available ✨
Get the care you need today and pay over time with Affirm & Afterpay. Ask our staff to learn more.