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Looking to send us your prescription? Prescriptions may be attached to your order while placing it online. If you do not have your prescription at the time of your order is created, simply attach it to your order later under “Orders” within your account.

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Shopper First Name *

Shopper Middle Name

Shopper Last Name *

Street Address *

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Apt/Suite No

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Patient Medical Questionnaire

In order to safely review your order, we require information about the prescribed patient.

If you are ordering for yourself, please provide your information.

If you are ordering for a family member or pet, please answer these questions on their behalf.

Patient First and Last Name *

Gender *

Male
Female
Other

Date Of Birth *

Patient Relationship *

Please indicate the patient’s height *

Please indicate the patient’s weight *

Current Medical Conditions - Please list patient's current medical condition(s) *

Drug Allergies - Please list patient's allergies and include any necessary comments *

Current Medication - Please list all medications/supplements patient currently takes *

Doctor's Information

First Name *

Last Name *

Clinic Name

Clinic Address

City

Apt/Suite No

Country:

State:

ZIP Code:

Acknowledgment *

By clicking 'create account' you agree to the terms and conditions set out in the customer agreement (including schedule 'a') as found here, and you agree, on behalf of yourself, your heirs, successors, administrators and assigns, to be bound by our terms of use.

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My account

Patient Medical Questionnaire

Doctor's Information

Pre-Mixed

Pens

Cartridges

Vials

Type 2 Diabetes (66)

Diabetes (44)

Type 1 Diabetes (38)

Kidney Disease (34)

Heart Failure (29)

High Blood Pressure (28)

Hypertension (20)

Stroke (18)

Heart Attack (15)

Depression (13)

High Blood Sugar (13)

Anxiety (11)

Angina (10)

Obesity (10)

Heart Disease (10)

Blood Glucose Monitoring (10)

Cardiovascular Disease (9)

Blood Clots (8)

Asthma (8)

Hyperglycemia (8)

Weight Management (8)

Panic Disorder (8)

Bipolar Disorder (8)

Atrial Fibrillation (8)

Psoriatic Arthritis (8)

Myocardial Infarction (7)

Major Depressive Disorder (7)

Post-Traumatic Stress Disorder (7)

Pulmonary Embolism (7)

Deep Vein Thrombosis (7)

Obsessive-Compulsive Disorder (7)

Ankylosing Spondylitis (7)

Neuropathic Pain (6)

Migraines (6)

Social Anxiety Disorder (6)

Diabetic Nephropathy (6)

Venous Thromboembolism (6)

Arrhythmia (6)

Diabetic Macular Edema (5)

Rheumatoid Arthritis (5)

Eye Conditions (5)

Hypoglycemia (5)

Left Ventricular Hypertrophy (5)

Chronic Obstructive Pulmonary Disease (5)

High Cholesterol (5)

Gestational Diabetes (5)

Diabetic Peripheral Neuropathy (4)

Plaque Psoriasis (4)

My account

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Patient Medical Questionnaire

Doctor's Information