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Complete Health Questionnaire

Please complete our health questionnaire below. If you have already completed this form or would like to complete it later, click here to checkout.

If approved, our physician will email your prescription information and shipping details. If not approved, your order will be cancelled/refunded. This form is HIPAA compliant and required by the FDA, in order mail prescription medication. If you don't want to fill out our health questionnaire, you may also call us at 1-800-692-1890 and speak with our nurse practitioner for a brief phone consultation.