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Format: (000) 000-0000.
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- Please select the medication(s) you wish to purchase. (Select more than one if applicable)*
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- Select the Reason for Requesting Provider Review (Ivermectin)*
- Select the Reason for Requesting Provider Review (Mebendazole)*
- Select the Reason for Requesting Ivermectin*
- Select the Reason for Requesting Mebendazole*
- Please select your current stage of Cancer*
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- Are you currently undergoing any of the following?*
- Are you COVID-19 Positive?*
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- Are you requesting Compounded Oral Ivermectin for supportive care in Current/Active or Future Covid-19 infection? (select "Yes" for treatment, and select "No" for requesting for prevention)*
- Are you requesting Compounded Oral Ivermectin for the Treatment of Long Covid (Long Haulers/ Post Covid condition)? (select "Yes" for Long Covid-19 treatment, and select "No" for requesting for prevention)*
- Are you requesting Compounded Oral Ivermectin for the prevention of Covid-19 infection?*
- Are you requesting Compounded Oral Ivermectin capsules for adjunctive treatment of Cancer?*
- Do you have a history of lice, skin parasites, or itching related to parasite exposure?*
- What are your current symptoms of parasite infection? Mark all that apply.*
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- Applicable only if taking Warfarin or other anticoagulants: I understand that Ivermectin may increase INR levels and raise bleeding risk. I agree to monitor INR and consult my provider if needed.*
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- Have you previously taken Mebendazole?*
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- Do you currently have severe liver disease or have a history of it?*
- Have you personally seen evidence of parasites on your skin or in your stool?*
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- Do you have numbness or reduced sensation in the planned treatment area(s)?*
- Are you currently using other pain treatments (topical or oral), including NSAIDs/acetaminophen, anticonvulsants, antidepressants, opioids, muscle relaxants, or other anesthetic creams/patches?*
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- Are you currently using other pain treatments (topical or oral), including NSAIDs, acetaminophen, opioids, muscle relaxants, nerve agents, or other anesthetic creams/patches?*
- Are you taking anticoagulants/antiplatelets (e.g., warfarin, DOACs, clopidogrel), or do you have a history of stomach ulcers/bleeding, severe kidney disease, severe liver disease, uncontrolled blood pressure, asthma triggered by NSAIDs/aspirin, heart rhythm problems,arrhythmia,A.Fibrilation, seizures, or heart failure?*
- Do you have numbness/tingling or reduced sensation in the planned treatment area(s)?*
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- Have you previously used topical retinoids (tretinoin/retinol) or topical antibiotics for acne?*
- Are you currently using other active skincare (e.g., benzoyl peroxide, AHAs/BHAs like glycolic/salicylic acid, azelaic acid, steroids) or had recent peels/laser/microneedling/waxing?*
- Have you taken oral isotretinoin (Accutane) in the past 6 months?*
- Have you ever had severe diarrhea or colitis associated with antibiotics (e.g., C. difficile)?*
- Do you have any medical conditions affecting skin healing or sensitivity (e.g., severe eczema/dermatitis, psoriasis, active rosacea flare, photosensitivity disorders, keloid tendency)?*
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- Have you previously used Hydroquinone, Tretinoin, or topical corticosteroids?*
- Are you currently using other active skincare (e.g., benzoyl peroxide, AHAs/BHAs/glycolic/salicylic acid, other vitamin C serums, retinoids, steroids) or had recent peels/laser/microneedling/waxing?*
- Do you have any medical conditions affecting skin healing or pigment (e.g., severe eczema/dermatitis, psoriasis, active rosacea flare, history of vitiligo or unusual loss of skin color, keloid tendency)?*
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- Are you currently using other active skincare (e.g., benzoyl peroxide, AHAs/BHAs/glycolic/salicylic acid, vitamin C serums, steroids), or had recent peels/laser/microneedling/waxing?*
- Do you have any medical conditions affecting skin healing or sensitivity (e.g., severe eczema/dermatitis, psoriasis, active rosacea flare, keloid tendency)?*
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- Are you using any other hair/scalp treatments now (e.g., topical/oral minoxidil, finasteride/dutasteride, spironolactone, ketoconazole shampoo, steroids, retinoids, PRP/microneedling)?*
- Are you using any other hair/scalp treatments now (e.g., topical/oral minoxidil, finasteride/dutasteride, spironolactone, ketoconazole shampoo, steroids, retinoids, PRP/microneedling)?*
- Have you ever been under care for prostate conditions (e.g., BPH, elevated PSA, prostate cancer) or had unexplained urinary symptoms (weak stream, urgency, night urination)?*
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- Are you using any other hair/scalp treatments now (e.g., topical/oral minoxidil, finasteride/dutasteride, spironolactone, ketoconazole shampoo, steroids, retinoids, PRP/microneedling)?*
- Do you have any current or past medical conditions (especially heart disease, chest pain, arrhythmia, low blood pressure, edema/swelling, kidney or severe liver disease, thyroid or iron issues, PCOS, major recent illness/surgery)?*
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- Have you ever taken Tadalafil or other ED medicines before?*
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- Do you use nitrates (nitroglycerin, isosorbide), recreational nitrites (“poppers”), or riociguat? (These must not be combined with Tadalafil)*
- Are you taking alpha-blockers (e.g., tamsulosin/doxazosin) or other blood-pressure–lowering meds?*
- Are you taking medicines that may interact (e.g., ketoconazole/itraconazole, ritonavir/cobicistat, clarithromycin/erythromycin, rifampin, carbamazepine/phenytoin, St. John’s wort, or grapefruit products)?*
- Do you have serious kidney or liver disease?*
- Do you have retinal disorders (e.g., retinitis pigmentosa) or a history of sudden vision loss/NAION?*
- History of hearing loss, ringing, or sudden decrease in hearing?*
- Any penile anatomy issues (e.g., Peyronie’s) or conditions that predispose to priapism (sickle cell disease, leukemia, myeloma)?*
- Any bleeding disorder or use of anticoagulants/antiplatelets?*
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- Have you ever taken Sildenafil or other ED medicines before?*
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- Do you use nitrates (nitroglycerin, isosorbide), recreational nitrites (“poppers”), or riociguat? (These must not be combined with Sildenafil.)*
- Are you taking alpha-blockers (e.g., tamsulosin/doxazosin) or other blood-pressure–lowering meds?*
- Are you taking any medicines that may interact (e.g., ketoconazole/itraconazole, ritonavir/cobicistat, clarithromycin/erythromycin, rifampin, carbamazepine/phenytoin, St. John’s wort, grapefruit products)?*
- Do you have serious kidney or liver disease?*
- Do you have retinal disorders (e.g., retinitis pigmentosa) or a history of sudden vision loss/NAION?*
- History of hearing loss, ringing, or sudden decrease in hearing?*
- Any penile anatomy issues (e.g., Peyronie’s) or conditions that predispose to priapism (sickle cell disease, leukemia, myeloma)?*
- Any bleeding disorder or use of anticoagulants/antiplatelets?*
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- Date*
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- Should be Empty: