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
What is your Height?*
What is your Weight?*
What is your Waist size?*
Where is the location of the pain?*
Is the pain on the right side or the left side?*

Does your pain radiate or travel to other places?

How long have you been having the pain?*
Is the pain constant or does it come and go?

What makes the pain worse or what starts the pain?*
Does activity make it worse?

What makes it go away or feel better? (ice, reduced activity, elevation, etc)*
On a scale of 1 to 10, what level of pain do you experience?*

Pain Chart
Do you have any swelling in the location of the pain?*

Do you have any redness in the location of the pain?*

Do you have any numbness?*

Is your pain due to any injury or accident?*

Have you had any surgeries for it?*

Is there any surgery planned for it?*

Have you tried any treatment for it?*

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 : 09/23/2020

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