ZipMeds Rx Medical History Form

ZipMeds Rx Medical History Form
Are you purchasing this kit for yourself?
Please Read

If the kit is for someone else, then we will need a full history and form to be completed for them. If there are multiple family members seeking a kit, then each will need a full history/ form and will receive a separate kit. You have to be 18 years or older to purchase the kit.

The prescribed medications take into account the individual’s medical status based on the clinical intake form, including any noted allergies. All medications have potential for allergic reactions and other adverse effects. Therefore, it is crucial to not allow others to use medications that were not prescribed for them.

The emergency medications should be handled with the same caution as any other prescription medication prescribed by a physician. It is important to adhere to the prescribed usage guidelines and avoid sharing the kit with family members unless explicitly advised to do so by a healthcare professional.

** all products to be sent to the address provided at check out. If multiple people receive products, they must reside in the same household and we will need health information on all family members who may be receiving and using the kit. IMPORTANT TO PROVIDE ACCURATE HEALTH INFORMATION. YOU WILL BE ASKED TO PROVIDE MEDICAL INFORMATION FOR ALL FAMILY MEMBERS WHO RECEIVE A KIT. IT IS IMPORTANT TO PROVIDE HEALTH INFORMATION TRUTHFULLY AND ACCURATELY FOR SAFETY PURPOSES
To get started, we need to know which state you currently live in?

Street Address

Street Address Line 2

CityState

Zip Code
Zip Meds RX doesn’t currently support orders for that particular state

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Patient Information
Full Name

First NameLast Name
Please enter a phone number that the doctor can reach you at if he/she has any questions re: your medical information
Format: (000) 000-0000.
Do you consent to receiving text messages about your prescription including tracking and refill information?
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your gender?
What is Your Date of Birth

MonthDayYear
Date
By checking here you agree to receive doctor correspondences and transactional messages from ZipMeds Rx to the email address provided

Do you use any kind of tobacco or have you ever used them?
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
*By checking this box, I acknowledge that I am seeking an evaluation by a licensed physician in order to have medications available for unforeseen medical emergencies and/or urgencies,resource shortages due to natural disaster/emergency scenario, for travel to locations abroadwhere modern medical care is not established or because I reside in an underserved medicalgeographic location
*By checking this box, I acknowledge*I am NOT seeking antibiotics to treat an active medicaldiagnosis/ problem
* By checking this box, I acknowledge I am NOT seeking antibiotics to replace, now or in the future, routine healthcare by my primary care doctor
Please provide your primary physician’s name here as well as a contact number
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Medications
Do you currently take any medications?
list all medications (name, dosage, frequency). If you use an inhaler, please specify the type and how often used.
Do you have any medication allergies?
Please list them.
YOUR DOCTOR NEEDS TO KNOW YOUR CURRENT MEDICATIONS TO SAFELY PRESCRIBE TO YOU BEFORE THEY CHECK AFFIRM.
FOR MEDICATIONS LISTED ABOVE, PLEASE ADD WHAT YOU WERE DIAGNOSED WITH. PLEASE LIST ALL MEDICAL CONDITIONS APPLICABLE TO YOU. INCLUDING : AUTO-IMMUNE DISEASES OR ANYTHING THATHAS WEAKENED YOUR IMMUNE SYSTEM.
Do you have asthma?
Is it under control?

Pregnancy and Breastfeeding
Are you currently pregnant or planning to become pregnant in the next six months?
Are you currently breastfeeding?

Antibiotic Use Affirmation
Affirm that you are not seeking antibiotics to treat an active diagnosis or condition.
Affirm that you are not seeking antibiotics to replace routine healthcare from your primary care physician.
If prescribed, affirm that you will store medications securely and out of reach of children.

Please give us the best days of the week and time of day (including time zone) to contact you by phone in the event a provider needs to speak to you
Time 1

Hour Minutes

AM/PM Option
Time 2

Hour Minutes

AM/PM Option
Should be Empty: