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Estrace 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 *
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
When was your last menstrual cycle?*
Are you premenopausal?*

Are you menopausal?*

Are you post-menopausal*

Have you recently had changes in your menstrual cycle? *

Have you noticed a decrease in the amount of vaginal lubrication during sexual activity?*

Have you noticed any chronic dryness, irritation, or urinary problems?*

Has there been any pain associated with sexual intercourse?*

Is the pain severe enough to limit your ability to engage in regular intercourse?*

Have you used any over-the-counter products, such as personal lubricants to alleviate your symptoms?*

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

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.
Photo ID
Only the medical team will see your photos

Date : 12/04/2020

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