Prescription Refill Form

Patient's Present State & Our Availability in that State *

Texas: 9am to 10pm CST

Verification

Cell Phone / Mobile Phone *

First Name *

Last Name *

Life Threat

Experiencing life-threatening symptoms or a medical emergency ? *

Yes, Stop! we do NOT treat life-threatening conditions online. CALL 911

Alert & Oriented

Are you alert and oriented? *

Yes

No, STOP! You must be alert and oriented to proceed

Reason for visit

Reason for this visit? *

Refill medication(s) that I'm currently taking

Resume medication(s) I was previously taking

Start a new medication that I have NEVER taken before. STOP! This form is to refill an existing medication. Return to our website and select a condition you would to treat

Current Health

Which of these best explains your current health status? *

My health and medical condition(s) are well controlled with my current medication

I still have symptoms that require me to take the medication(s)

I have a complicated and severe medical condition that require close monitoring. STOP! Given the severity of your condition you're not a candidate for telemedicine

Anti-fungals often cause liver injury with recurrent use

When was your last liver lab test (ALT, AST)? *

Normal liver labs in the last 6 months

I have never had a liver lab test

I have NOT had a liver lab test in the last 6 months

My last liver test were ABNORMAL or I have a history of liver disease. STOP! Unfortunately you're not a candidate for an antifungal due to your underlying liver condition.

Common names for antifungal medicines include: clotrimazole (Canesten), econazole, miconazole, terbinafine (Lamisil), fluconazole (Diflucan), ketoconazole (Daktarin), nystatin (Nystan), amphotericin, etc.

Side Effects

Are you tolerating the requested medication(s) with NO significant side effects? *

Yes! No significant side effect with my medication(s)

No! I experience significant side effects of one or more of my medications. STOP! Medication with adverse side effect will not be refilled.

Over 3 months since last refill

Been over 3 months since your last refill? *

Yes,STOP! we can not refill.

Reason Doctor or Specialist unable to refill

Reason your primary doctor or specialist is unable to refill your prescription *

Doctor’s office is closed, Need ongoing medication

Doctor is unavailable (e.g., on vacation)

I'm traveling and can't access my doctor. I need a refill for a limited time.

I lost my ongoing medication and can't reach my doctor's office

There’s a supply issue with my regular pharmacy, and I need a temporary solution.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

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