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Who is the patient?

My Self

Another Person

Personal information

PERSONAL INFORMATION

First Name *

Last Name *

Date of Birth (DOB) *

Biological Sex *

Phone *

SMS Consent to recibe important information (optional)

Photo Upload

Your telemedicine physical or practitioner needs to see these to confirm your identity. Please provide:

Selfie photo

Note: if your are providing photos for any medical condition including skin conditions, please ensure we have a close up and clear photo to avoid any treatment delays.

State regulations require we verify identification before a medication can be issued

Selfie photo *

Selfie Sample

SHIPPING ADDRESS

YOUR ORDER

Product

Qty

Price

Strength

$

Subtotal

$0.00

Discount

(0%) $0.00

Shipping

$0.00

Tax (Tax no currently calculated, will be based on address.)

$0.00

Total

$0.00

Coupon

Note:

Your card will only be pre-authorized at this time. Once our doctors have reviewed and approved your order, your card will be charged and you'll receive your order in the mail.

PAYMENT METHOD

NAME ON CARD

CARD NUMBER

BILLING ADDRESS

Next: Medical Questions

This step is important to help the doctor understand your medical situation and be able to prescribe the best medicine for you.

Who is the patient?

My Self

Another Person

Why do you need a photo ID and selfie?

Next: Medical Questions

0 Shipping Address

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