Home
Services
General Health
Sexual Health
Medications
Men Health
Labs
Shop
FAQs
X
Facebook-f
Twitter
Behance
Pinterest-p
Home
Services
General Health
Sexual Health
Medications
Men Health
Labs
Shop
FAQs
Menu
Home
Services
General Health
Sexual Health
Medications
Men Health
Labs
Shop
FAQs
Contact Now
General
Health
General Conusltation Form
Full Name
.
Date of Birth
Please enter your date of birth
Gender
Male
Female
Please select your gender
Phone Number
Please enter your phone number
Are you under the age of 18 ?
Yes
No
Email Address
Please enter your email address
Email Address
Please reenter your email to confirm its correct
Street Address
City
State
ZIP Code
Do you have a fever
Yes
No
Do you have any medical conditions?
Yes
No
If yes, please list your medical condition
Please enter your medical condition
Do you have any allergies?
Yes
No
If yes, please list your allergies
Are you taking any medicines, supplements, herbal remedies, or other prescriptions
Yes
No
If yes, please list your medications
Do you have chronic liver, Heart or Kidney problems?
Yes
No
If yes, please list your problem
Are you Pregnant or breastfeeding?
Yes
No
If yes, please list your problem
Reside in the state of Michigan?
Yes
No
If yes, please list your problem
Are you on Medicare or Medicaid?
Yes
No
If yes, please list Medicare or Medicaid
How severe are your symptoms?
Mild
Moderate
Severe
Please describe the outbreak?
Vaginal or penile discharge
None
Other
Other
Do you have any of these symptoms?
one or more small, flesh-coloured or grey painless growths or lumps around your vagina, penis, anus or upper thighs
itching or bleeding from your genitals or anus
a change to your normal flow of pee (for example, sideways), that doesn't go away
Warts can appear as a single wart or as multiple warts in a cluster.
Other
Other
Have you had a Yeast Infection before?
Yes, diagnosed by a doctor
Yes, self-diagnosed
No
Terms of Use and Privacy Policy
I consent to treatment by the healthcare provider named above for the medical conditions indicated. I acknowledge that I have provided complete and accurate information to the best of my knowledge.
See the following links for Term of Use and Privacy Policy
Pharmacy name
Pharmacy Phone Number
Pharmacy Address
Billing Name
.
Billing Address
Credit / Debit Card
*
Submit
ANSWER HEALTH QUESTIONS
Tell us about your health, medical history and symptoms.
TREATMENT
Your personalized treatment plan will be sent to the pharmacy of your choice within a couple of hours.
PICK UP
Pick up your medication at your pharmacy or lab. Yes its that simple !
Previous slide
Next slide
TREATMENT
Your personalized treatment plan will be sent to the pharmacy of your choice within a couple of hours.
PICK UP
Pick up your medication at your pharmacy or lab. Yes its that simple !
ANSWER HEALTH QUESTIONS
Tell us about your health, medical history and symptoms.
Previous slide
Next slide
ANSWER HEALTH QUESTIONS
Tell us about your health, medical history and symptoms.
TREATMENT
Your personalized treatment plan will be sent to the pharmacy of your choice within a couple of hours.
PICK UP
Pick up your medication at your pharmacy or lab. Yes its that simple !
Previous slide
Next slide
