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Electronic Medical Consultation

General Medication Refills – 1 Month

Fee: $40.00

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What is the name of your medication?

What is the dosage?

How frequently do you take it?

Why do you need refills?

What is the diagnosis/ reason for taking this medication?

How long have you been on this medication?

When was this medication last filled?

Name of Physician who last filled medication.

Pharmacy name and phone number where prescription was last filled?

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Additionally, you acknowledge that you understand you’re engaging in an online medical consultation and that you hereby consent to receive healthcare services from one of our medical providers (MD, PA, NP, or DO).

You understand that our healthcare providers reserve the right to deny care for any reason.

You acknowledge that you have a complete understanding of the risks and advantages associated with online medical consultations.

I have read and agree to the informed consent agreement.

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Consultation

General Medication Refills – 1 Month

Before You Continue - Please Review Our Informed Consent Agreement

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