Are you in one of the following areas in the State of Florida?
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Miami-Dade County
Miami-Dade County
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Palm Springs County
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First Name
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Last Name
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Email
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Phone
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Address
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Gender
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Male
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Date of birth
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Name of medication
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What is the name of your doctor?
What is the phone number of your doctor?
Name of the Pharmacy managing your prescriptions
Pharmacy phone number
Anything else we should know about your medical history?
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Yes
No
Please type the name of the medications you need
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Please upload a picture of your prescription
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Please upload a picture of the front of your insurance card
Please upload a picture of the back of your insurance card
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