GPCRMedical

Personal Data

Shipping Address

Medical Data

Please explain the specific medical reason for ordering this medication. The prhysician must know the exact nature of your medial problem in order to prescribe this medicantion.

Please list all your past and present medical and psychiatric condition including any surgery or other procedures.

Please list all prescriptions and over-the-counter medicantios that you are currently taking and the length of time for each.

Please list past or present allergies including allergies to any medications.

Are you Type 1 Diabetes, Type 2 Diabetes, or None.

Have you Ever Experienced Heart Failure?

Yes

No

Do you have a history of Liver or Kidney Disorders?

Yes

No

Do you Consume Alcohol?

Yes

No

Are you currently takin any anti-inflammatory medicine?

Yes

No

Are you takin any Antidepressant or Antianxiety medicine?

Yes

No

Have you been preescribed this medication before?

Yes

No

Please share name of last doctor that prescribed this product, state, and date of last refill? NO DOCTORS WILL BE CALLED. Type: NONE 1st time. If it is your first time.

Do you have the condition called Porphyria?

Yes

No

If your gender is female please answer the question. Otherwise type "none". are you currently or within the last 12 months been pregnant or nursing? Do you plan on getting pregnant soon?

For your Telehealth appointment. At what time would you prefer the doctor to speak to you. To go over the questionnaire prior to writing your prescription to the pharmacy. The doctor attendes between 11am EST to 5pm EST. NO SOFTWARE IS NEEDED FOR THE TELEHEALTH CONSULTATION

Card Info

Is the billing address the same as the shipping address?

Yes

No

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