MinuteMD General Initial Enrollment Form

1
This questionnaire is for patients who are NEW to MinuteMD and it will ask you various health-related questions in order to provide you with your requested medication.

It is extremely important that you answer the questions honestly.

It is expected that it will take most people approximately 10 minutes to complete this questionnaire and it will require you to provide a picture of a current, non-expired US-government issued photo identification to match the name of the patient.
2
What is the patient's full name (as it appears on US-government issued photo ID)?* This field is required.
First Name
Last Name
3
What is the patient's date of birth?* This field is required.
Date
Month
Day
Year
4
What is the patient's email address?* This field is required.
example@example.com
5
What is the patient's best phone number if the providers have any questions?* This field is required.
Please enter a valid phone number.
6
What is the patient's shipping address? This is where orders will be shipped.* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Please take a photo of your US-government issued photo ID. Failure to provide this now may delay your order and our customer service team will reach out to you to provide this within 24 business hours.
8
What was your sex assigned at birth?* This field is required.
Male
Female
9
Please enter your current height and weight:* This field is required.
10
Are you currently pregnant, planning to become pregnant, or breastfeeding?* This field is required.
YESNO
11
Since you indicated you are pregnant, planning to become pregnant or breastfeeding, please explain in more detail for the provider's review:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Do you have a history of chronic urinary tract infections?* This field is required.
YESNO
13
Since you indicated YES to urinary tract infections, please explain in more detail:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
14
Do you have a history of mold illness or chronic lyme disease?* This field is required.
YESNO
15
Please tell us more about your medical condition(s) that you have indicated above:* This field is required.
16
Have you ever been infected with COVID-19?* This field is required.
YESNO
17
Do you suffer from Post COVID-19 Syndrome?* This field is required.
YESNO
18
Do you suffer from brain fog and/or memory issues?* This field is required.
YESNO
19
Do you have a family history of dementia and/or Alzheimer's Disease?* This field is required.
YESNO
20
Are you looking for a boost in energy, ATP production and/or mitochondrial function?* This field is required.
YESNO
21
Do you want something that optimizes NAD+ production in your mitochondria?* This field is required.
YESNO
22
Do you take any monoamine oxidase (MAO) inhibitors for depression?* This field is required.
Phenelzine (Nardil)
Selegiline (Emsam)
Yes, I take a monoamine oxidase (MAO) inhibitor, but it is not listed above.
No, I do not take any monoamine oxidase (MAO) inhibitors.
23
Do you take specific serotonin reuptake inhibitors (SSRI) for depression?* This field is required.
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Paroxetine (Paxil, Pexeva)
Sertraline (Zoloft)
Yes, I take a specific serotonin reuptake inhibitor (SSRI) but it is not listed here.
No, I do not take any specific serotonin reuptake inhibitors (SSRI).
24
Do you take medication for attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)?* This field is required.
Amphetamine (Adderall, Adzenys)
Dextroamphetamine (Zenzedi)
Methylphenidate (Ritalin, Concerta, Delmosart, Equasym, Medikinet)
Dexmethylphenidate (Focalin)
Yes, I take ADD/ADHD medication but it is not listed here.
No, I do not take any ADD/ADHD medication.
25
Are you searching for a brain booster/nootropic agent that is FDA approved?* This field is required.
YESNO
26
Are you looking for an anti-microbial agent that enhances and optimizes health while having no negative effects on your gut?* This field is required.
YESNO
27
Would you be interested in an agent that preserves telomeres and cell life?* This field is required.
YESNO
28
Do you have ANY allergies? This includes food or medicine.* This field is required.
YESNO
29
Since you indicated you have allergies, please explain them in more detail:* This field is required.
30
Please list ALL prescription medications you are currently taking, if any. If none, write NONE.* This field is required.
31
Do you have any recent bloodwork you feel would be helpful to share with your provider? This is not required and you may skip this step if you do not.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
32
How would you rate your current energy levels on a scale of 1 to 10?* This field is required.
33
How would you rate the quality of your sleep on a scale of 1 to 10?* This field is required.
34
Do you follow a specific diet or have any dietary restrictions? Please explain:
Huge
Large
Normal
Small
Ok
Ok
35
How often do you engage in physical activity/exercise?* This field is required.
Please Select
Please Select
Daily
Several times a week
Once a week
Rarely
Never
36
What goals would you like to achieve with this treatment?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
37
Signature* This field is required.By my signature below, I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
Clear
38
Important Reminders

This questionnaire is for informational purposes only and should not be considered medical advice.

A healthcare professional will need to review your medical history and conduct an evaluation to determine if your requested therapy is right for you.

It is crucial that you were honest and provided accurate information in your responses to this questionnaire.

If the healthcare professional determines you are not eligible for your requested treatment, your order will be cancelled and refunded automatically.

This medication, if approved, will be shipped to you with enough supply for approximately 10-12 weeks. As such, a minimum subscription period of 3 monthly charges applies to this order.
39
Available Treatment Options* This field is required.Please choose only ONE (1) therapy that you would like to request with this order. If you would like to choose multiple therapies, you will be presented with options during checkout to add-on additional therapies.
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ORDER SUMMARY
Total costUSD
NAD+ TherapyNAD+ (nicotinamide adenine dinucleotide) is a coenzyme that plays a vital role in various metabolic processes including energy production and DNA repair.
$170.00Edit
Back
Glutathione TherapyGlutathione, often referred to as ‘the master antioxidant,’ aids the body in detoxifying from the impacts of aging and stress. (Monthly subscription required, 3 month minimum required.)
$99.00Edit
Back
Methylene Blue TherapyAs a nootropic, Methylene Blue quickly crosses the blood-brain barrier. It improves mitochondrial efficiency and respiration, acts as an antioxidant, and increases brain cell lifespan all resulting in improved memory and mood. (Monthly subscription required, 3 month minimum required.)
$199.00Edit
Back
B-12 TherapyB-12 is an essential vitamin our bodies need. And when combined with a Semaglutide, Tirzepatide or Liraglutide treatment can increase energy levels, enhance exercise performance, increase nutrient absorption, regulate blood sugar levels and support metabolism. This is a one time order which includes doctors fees, (1) vial of injecable B12 including 10 weeks of injections, injection supplies and shipping directly to you.
$99.00Edit
Back
Total cost $0.00
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Important Reminders