1. I agree not to take any over-the-counter medicines without approval from my pharmacist.
2. I agree not to take this medication if I am pregnant, breast feeding, or trying to get pregnant.
3. Please list any and all medical conditions (heart disease, BP, seizures, etc). Enter "None" if none.
4. Is there anything in your medical history relevant? Enter "None" if none.
5. List all current medications (OTC and Prescription). Enter "None" if none.
6. List all past or present allergies to medications. Enter "None" if none.
7. Are you taking any controlled substances (anti-anxiety, sleep, pain)? Enter "None" if none.
8. Taking Opioids, narcotic pain meds, nitrates, or Suboxone? Enter "None" if none.
9. Ever treated for mental health or substance abuse? Enter "None" if never.
10. Ever experienced or been treated for a seizure? Enter "None" if never.
11. History of liver or kidney disease? Enter "None" if no.
13. Do you drink alcohol? Enter "None" if no.
14. Have you taken this medication before? Specify date and source.
15. Explain specific medical reason for ordering (Required).
Disclaimer: By submitting this order, I confirm that the medical questionnaire I have completed contains my full and accurate medical history and that all information provided is true and correct to the best of my knowledge. I confirm that I am an adult (at least 21 years of age) and that I am competent to use the services offered.
I acknowledge that I have reviewed and agree to the Terms of Service and Privacy Policy. I understand and agree that the pharmacy and/or medical provider may review my prescription history, for the purpose of evaluating my eligibility for treatment and fulfilling my order. I understand that providing false, misleading, or incomplete medical information may result in denial of service or cancellation of my order. I understand that once my order has been processed and shipped by the pharmacy, cancellations or refunds will not be accepted.
By submitting this order, I confirm that I have reviewed all information provided and verify that it is accurate and complete to the best of my knowledge. I understand that telehealth services are not intended to replace ongoing care from a primary healthcare provider, and I am responsible for seeking in-person medical care when appropriate.