Men's Health

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Preferred Contact Method

I consent to receive texts that may contain private information from Moundsville Pharmacy.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Care Provider:

Have you had any lab work completed within the past 12 months?

What area(s) of Men's Health are you most interested in improving?

Share any additional comments, questions or concerns here:

Notice Regarding Electronic Submission of Information

By submitting this form, you acknowledge and agree that the information you provide will be transmitted electronically via email to Moundsville Pharmacy for the purpose of reviewing your inquiry, request, or interest in pharmacy services and facilitating appropriate follow-up communication.

Please be aware that standard email communications are not guaranteed to be secure or encrypted. While Moundsville Pharmacy takes reasonable measures to protect the confidentiality of information it receives, electronic transmission via email carries inherent risks, including the possibility of unauthorized access, interception, disclosure, alteration, or loss of information during transmission.

By submitting this form, you understand and accept these risks and consent to the transmission of your information through electronic means. If you prefer not to transmit health-related or personal information electronically, please contact the pharmacy directly to discuss alternative methods of communication.

Submission of this form does not establish a patient-provider relationship, guarantee eligibility for any product, treatment, or service, or obligate either party to proceed with services.