Anava Intake Form

1
Which state do you currently reside in?* This field is required.(Note: At this time, we only serve select states for prescription eligibility. We will add more states soon.)
Please Select
Please Select
Alabama
Alaska
Arizona
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
Oregon
Ohio
Oklahoma
Pennsylvania
Rhode Island
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
2
What are you interested in today? (select any that apply)* This field is required.This helps us tailor the best wellness plan, personalized for you.
Weight loss (GLP-1s like Semaglutide or Tirzepatide)
Wellness peptides (NAD+, Glutathione, etc.)
Sexual wellness
3
Which plans are you considering today?* This field is required.Please check all that apply so our providers can tailor your review accordingly. This helps us match your intake with your order.
Please Select
Compounded Semaglutide
Compounded Semaglutide + B3
Compounded Tirzepatide
Compounded Tirzepatide + B6
Compounded Tirzepatide + B3
Compounded Liraglutide
Other GLP-1 Plans
NAD+ (Injection)
NAD+ (Capsule)
Glutathione (Injection)
Sermorelin (Injection)
Bioboost Plus (MIC/B12/Arginine)
Mount Rushmore (Male Performance Troche)
ErecMax Capsule (Sildenafil + L-Arginine)
Trimix Injectable
Scream Soft™ (Female Sensitivity)
Oh My Gush™ (Female Libido)
Scream Deep™ (Female Performance)
EstroSoft™ (Estradiol)
Other: Wellness or Sexual Health
4
Have you ever used a GLP-1 medication (Semaglutide, Tirzepatide, Ozempic, Wegovy, Mounjaro, etc.) before?* This field is required.Answer ONLY if you’re seeking weight loss therapy. This helps our providers determine the safest and most appropriate dose. If you aren't seeking weight loss, please type: N/A.
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5
If you’re selecting a GLP-1 (Compounded Semaglutide or Compounded Tirzepatide), what is your reason for using a compounded version?* This field is required.This is required for provider review.
I’ve experienced errors using the commercial brand’s injector pens
I need additional metabolic support with my GLP-1 for tolerance (such as: B-vitamins, glycine, or etc.)
I need the flexibility to adjust my medication dose, to reduce side effects
I don't have a clinical need for a GLP-1
I’m not selecting a GLP-1 today
6
Are you currently pregnant, breastfeeding, or planning pregnancy?* This field is required.
YESNO
7
Have you ever been diagnosed with any of the following?* This field is required.
Type 2 diabetes
PCOS (Polycystic Ovary Syndrome)
Hypothyroidism
High blood pressure
Kidney or liver disease
Gallbladder disease
History of pancreatitis
History of thyroid cancer or MEN2
None of the above
8
Have you ever used hormone therapy (like estrogen, testosterone, or HRT)?
Yes
No
Not sure
9
Are you currently experiencing any of the following symptoms?These can be signs of hormonal imbalance, fatigue, or metabolic issues.
Low sex drive
Fatigue
Hot flashes or night sweats
Mood changes or irritability
Brain fog or memory issues
Weight gain or difficulty losing weight
None of the above
10
Do you have any sexual health concerns you’d like us to consider?This helps us understand if specialized support may benefit you.
Low libido or sex drive
Vaginal dryness or discomfort
Difficulty achieving orgasm
Erectile difficulty or loss of firmness
Performance anxiety or self-confidence issues
None of the above
11
Do you have any known allergies to medications, injections, or supplements?If yes, please describe your reaction and the substance.
12
Are you currently taking any medications or supplements?If yes, include prescription medications, over-the-counter meds, vitamins, and supplements. Include names, dosages (if known), and how often you take them.
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13
What is your height?* This field is required.
14
What is your current weight? (Lbs)* This field is required.
15
What is your name?* This field is required.
First Name
Last Name
16
What is your date of birth?* This field is required.
Date
Year
Month
Day
17
Please upload a clear photo of your government-issued ID or passport.* This field is required.This is REQUIRED before any prescriptions are approved or shipped. It allows us to verify your identity, confirm you’re over 18, and comply with federal regulations for prescription medications.
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Select files to upload
Max. file size: 10.6MB
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18
Please upload your previous GLP-1 prescription, IF any.PLEASE READ: FOR COMPOUNDED SEMAGLUTIDE, IF YOU'RE REQUESTING A DOSE HIGHER THAN 0.25MG, YOU MUST UPLOAD PROOF OF A PREVIOUS OR CURRENT PRESCRIPTION. FOR COMPOUNDED TIRZEPATIDE, IF YOU'RE REQUESTING A DOSE HIGHER THAN 2.5MG, YOU MUST UPLOAD PROOF OF A PREVIOUS OR CURRENT PRESCRIPTION. THIS IS REQUIRED PER ANAVA HEALTH'S MEDICAL PROVIDERS TO PROMOTE PATIENT SAFETY.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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19
What’s the best email to reach you?* This field is required.
example@example.com
20
What’s your mobile number?* This field is required.
Area Code
Phone Number
21
Shipping Address* This field is required.Please include apt number, if any.
Street Address
Street Address Line 2
City
State / Province
Postal / 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
22
About your Rx request and provider approval* This field is required.Submitting this intake form and/or purchasing a plan does not guarantee full medical approval or prescription. All orders & intake forms are reviewed by a licensed provider, and prescriptions are only issued when clinically appropriate and per individual clinical need. If for any reason you are not approved, your order will be fully refunded or the authorization hold on your card will be released.
I understand that any purchase I make will only be finalized upon provider approval, and I will be fully refunded or not charged if I am not approved.
23
Please review and confirm the following statements:* This field is required.These acknowledgments are required to ensure safe, responsible, and compliant care.
I confirm that I am at least 18 years old and submitting this intake on my own behalf.
I acknowledge that I may experience side effects with my treatment, and I will notify my telehealth provider and a PCP.
I understand that a government-issued photo ID is required before any prescription can be processed.
I understand that Anava Health offers compounded medications that are not FDA-approved, but may be legally prescribed by licensed providers based on clinical need.
I understand that Anava Health is a telehealth service and that my care may be provided virtually without an in-person exam.
24
Required: Please Read Before Continuing* This field is required.By checking below, I acknowledge that I must first submit my medical intake form (which I am completing now). I understand that upon pre-approval, this form will redirect me to the Anava Health catalog where I must select my prescriptions and complete checkout, which serves as my prescription request. Finally, I understand that I must join the Anava Health patient portal and/or respond to Anava’s emails in order to chat with my provider and receive updates.
Yes, I understand and acknowledge
Yes, I understand and acknowledge that after selecting a plan on tryanava.com, that final provider review & approval may take up to 24 to 48 business hours.
25
🎉 You’re Pre-Approved! Head back to our catalog to choose your plan(s) and check out.PLEASE NOTE: A FINAL REVIEW BY A MEDICAL PROVIDER IS STILL REQUIRED. Tap ‘submit’ below to finish👇
I’m excited to start my journey!
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