Clomid Medical Intake Form

You have purchased a prescription product. To complete your order complete the form below and we will forward your information to one of our participating providers who can treat you from the comfort of your home.

First Name*
Last Name*
Phone Number *
Email *
Address*
City *
State Of Residence*
Zip Code*
Are you allergic to any medication? *
What medications or vitamins are you taking? *
What is your date of birth? *
Gender* Female Male
Are you currently trying to get pregnant?*


How long have you been attempting to get pregnant?*
How frequently have you been having intercourse in your pregnancy attempt?*
Have you had a prior pregnancy that resulted in a healthy birth?*


How many successful pregnancies have you had in the past (including ectopic & miscarriages)*
Have you ever miscarried?*


How regular is your menstrual cycle?*



When was your last menstrual cycle?*
Have you missed any periods?*


How old were you when your periods first began?*
How long (in days) is your average menstrual cycle?*
How would you describe your periods; light, medium or heavy?*



Have you noticed any breast tenderness?*


Have you noticed any hot flashes?*


Have you noticed any changes in body hair growth or body weight?*


Have you had any abnormal breast discharge?*


Have you been diagnosed with or had any of the following? Select all that apply.*



















If you have been on oral contraceptives, how long has it been since you stopped them?*
Have you used any lubricants, some of which, may be toxic to sperm?*


Have you had any prior infertility testing or therapies?*


Do you have any family history of birth defects, genetic abnormalities, mental retardation, or reproductive failure?*


We must have a clear photo of your face and your photo ID so that we may properly identify and treat you. Your information is kept strictly private. We are a HIPAA compliant website. Take a pic right from your phone or upload a photo from your computer.
Faceshot
Photo ID
Only the medical team will see your photos

Date : 09/21/2020

Note: Your medical information will not be saved until you click on the SUBMIT button.