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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?*



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 : 12/04/2020

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