Medication Request Form

1
Are you requesting a new medication or a change to an existing medication?* This field is required.
New Medication
Refill or Change to Existing Medication
2
Medication Name* This field is required.
3
Dosage and Instructions (if known)
4
Reason for Request (please explain why you are requesting this medication or change)* This field is required.
5
Additional Comments or Information
6
Physician, PA, or NP that normally provides this medication
7
Allergies
8
Any new health conditions
9
Prior Surgeries
10
Current Medical Conditions
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11
Patient Attestation & Acknowledgement* This field is required. I certify that the information I have provided, including my symptoms, medical history, medications, allergies, and other requested information, is complete and accurate to the best of my knowledge. I confirm that I am physically located in the State of Utah at the time I submit this request for care.I understand that this is an asynchronous telehealth visit, meaning that I will not necessarily communicate with a healthcare provider in real time. A licensed healthcare provider will independently review the information I submit, along with any other available or requested clinical information, before making any diagnosis, treatment recommendation, or prescribing decision.I understand that the provider may request additional information, photographs, medical records, laboratory testing, a telephone or video visit, or an in-person evaluation if needed to safely evaluate or treat my condition. Submission of this questionnaire does not guarantee that treatment or a prescription will be provided.I understand that telehealth has limitations and that certain conditions cannot be safely diagnosed or treated through asynchronous care. If the provider determines that telehealth evaluation is not appropriate for my condition, I may be advised to seek in-person medical care.I certify that I am not currently experiencing a medical emergency. If I develop severe, rapidly worsening, or potentially life-threatening symptoms, I will not wait for a response through this service and will call 911 or seek care at the nearest emergency department.I understand that if my symptoms persist, worsen, change significantly, or do not improve as expected, I should seek additional medical evaluation as directed by my healthcare provider.
YESNO
12
Basic Information
Full Name
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Date of Birth
13
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ORDER SUMMARY
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Payment Methods
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First Name
Last Name
Google Pay
After submitting the form, you will be redirected to the Google Pay to complete the payment process.
Apple Pay
After submitting the form, you will be redirected to the Apple Pay to complete the payment.
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