Rectal Rocket 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
Have you had any rectal bleeding, including but not limited to, bright red blood on toilet paper, stool, or in the toilet bowl?*

Did a specific event cause these symptoms to start? *

Have you been examined by a physician for this symptom?*

Have you noticed any of the following?*


Have you noticed itching or increased irritation in your anal region?*

Would you describe your bowel movements as painful?*

Do you feel as though you have to strain when passing stool?*

Have you noticed any hard or painful lumps near the anus?*

How much fiber do you consume daily?*



How much water do you consume on a daily basis; be specific?*



How often do you suffer from constipation?*



How often do you have a bowel movement?*



What medications, if any, have you tried in the past to treat your symptoms?*
Have you ever been diagnosed with rectal prolapse, chronic hemorrhoids, or fecal incontinence?*

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 : 07/07/2020

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