Are you in one of the following areas in the State of Florida? *

First Name

Last Name

Please check the box to receive SMS communications from PharmcoRx Pharmacy in regards to my treatment.

I agree to receive SMS communications from PharmcoRx Pharmacy in regards to my treatment.

Consent

To ensure the medication we prescribe is safe for you, next please answer a few questions from our medical team.

Your answers will be kept confidential, and only used to make sure we provide the right care for you.

This telehealth session is not a replacement for a primary care relationship or annual physical wellness exam. We encourage you to see your health provider at least once a year.

By starting a consultation, you consent to our Terms of Use, Privacy Policy, & Telehealth Consent Policy

Email *

Please check the box to agree with our Terms of Use, Privacy Policy, & Telehealth Consent Policy

I consent to our Terms of Use, Privacy Policy, & Telehealth Consent Policy

Gender

Date of birth

Height

Weight

How many cigarettes do you smoke per day?

Have you ever been diagnosed with HIV?

Yes

Do you currently have a prescription for PrEP?

Yes

Name of medication

Name of the Pharmacy managing your prescriptions

Pharmacy phone number

Do you think your current lifestyle puts yourself at risk of HIV? *

Yes

Have you ever been diagnosed with the following conditions? *

Are you currently taking any prescription medications, over the counter drugs or herbal supplements, including supplements on a regular basis? *

Yes

Please list all medications you are currently taking

Do you have any drug allergies? *

Yes

Please list your known medication allergies

Anything else we should know about your medical history? *

Yes

Let us know about any concern you may have!

Please select your insurance plan (select all that apply)

Please upload a picture of the front of your insurance card

Please upload a picture of the back of your insurance card

Select a medical office within our network to get your prescription *