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Prevention Packages
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Telehealth visit and supply of recommended medications ($ for day supply).
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First Name
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Last Name
*
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Email
*
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Mobile Phone
*
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Mobile # for texting. Don't include "1" in front of phone number.
Date of Birth (e.g, 12/15/1975)
*
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Date format must be mm/dd/yyyy
Gender
*
Male
Female
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Address
Address Line 1
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Address Line 2
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City
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State
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AL
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DE
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FL
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ID
IL
IN
IA
KS
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LA
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MA
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PA
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SC
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TN
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UT
VT
VA
WA
WV
WI
WY
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Zip
*
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Past Medical Problems
*
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e.g. Diabetes (if none, type "none")
Current Medications
*
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If none, type "none"
Known Allergies
*
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Medication and/or environmental. If none, type "none".
Medication or Lab Request
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Just a suggestion... Provider will make final determination.
Reason for Medication
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Provide as much detail as possible
Weight
*
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lbs
Costs
Total Fee
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Payment
After you submit your request, a licensed medical provider will review your information and you will receive a response via email or text message as soon as possible. Your credit will be charged immediately. Some HSA credit cards might not be accepted if a card processing error is shown.
By clicking the "Submit Request" button below, you confirm that you are the patient or legal guardian thereof, and you agree to the Terms of Use.
You must use your credit card statement billing zip code.
Credit or Debit Card
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Yes, I agree
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