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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 ever been diagnosed with Herpes?*


Are you currently experiencing an outbreak?*


Have you ever had a cold sore or herpes outbreak in the past?*



Date : 09/20/2021

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