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Medication
Form
Medication Consultation 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
What do you need the medicine for?n(Please select all that apply)
*
Bronchitis/Chest infection
Pneumonia
STDs
Ear infection
Lung infection
Sinus/nasal infection
Skin infection
Throat infection
Please briefly describe the infection/ treatment needed
*
How long have you had the infection?
*
1-3 days
3 to 7 days
over 7 days
Do you consider your infection?
*
Mild
Moderate
Severe
We appreciate our patient's contribution to their own care. Select your drug of choice, if any, from our treatment options below
*
Azithromycin
Let NostressMDs medical providers deide
Add prescription diflucan for yeast infection - $10 more
*
Yes
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 Terms 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 !
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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
