Intake – MyDrHank

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Full Intake Progress
Status
Tags
time_zone
Stage
Disposition
Visit ID
phone_primary*
Phone*
Email Address
Preferred Contact Method*
What would be your preferred contact method for us or even the Doctor to be able to contact you if necessary?
- Phone
- Text
- Email
Teledoc Option*
- Use my doctor and save 50%
- Help me find a doctor. (Not available in NC and SC)
Consent*
I agree to these terms
You consent to being treated via telemedicine and being contacted via email, phone, or text. For more details regarding this consent you can visit mydrhank.com
Telemedicine Privacy Policy
Telemedicine Informed Consent
Product Name
- SILD 20mg x25
- SILD 20mg x50
- SILD 50mg x10
- SILD 50mg x20
- SILD 100mg x5
- SILD 100mg x10
- SILD 100mg x20
- SILD 100mg x30
- TADA 5mg x30
- TADA 10mg x5
- TADA 10mg x10
- TADA 10mg x25
- TADA 20mg x5
- TADA 20mg x10
- TADA 20mg x20
- TADA 20mg x30
- TROCHE 12 doses
- TROCHE 20 doses
- TROCHE 40 doses
- PARO 20mg x30
- SERT 50mg x30
odoo_frequency
odoo_drug
Hidden Size
odoo_quantity
odoo_subscription
odoo_price
Conditions
Drugs
Allergies
Name*
Please verify your name here
First Name Last Name
What’s the address where you’d like me to send the medication to? Can I have your street address please?
Shipping Address*
Street Address City State Ex: FL or Florida ZIP / Postal Code
Please make sure a valid State is entered
Unfortunately we cannot ship this prescription to this address. Please select a different prescription or enter a different valid Shipping Address. You may also choose to Use your Primary Care/Urologist or contact us for assistance at 888-588-8094.
Hidden State
May I get your date of birth please?*
Date Format: MM slash DD slash YYYY

Must be 18 years or older
Hidden DOB
DOB Pass Fail
- fail
- pass
Doctor Selection Type
- Personal
- Beluga Health
- Upscript
Phone Verification
- verified
- unverified
- start
Phone Verification Pass/Fail
- pass
- fail
- skip
- start
We just need to validate your phone number before we can send you messages. Please click 'Validate Phone #' below.
Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number or a different contact method.
Thank you for verifying your number!
Phone
Identity Verification
Please click the 'Start Verification' button to begin the process. If necessary we may need to ask a few questions just to verify your identity.
We do not have enough information to verify your Identity. Please make sure all fields are filled in above and click 'Start Verification' again.
We were not able to verify your Identity. Please double check your information then click 'Start Verification' again.
Thank you for verifying your Identity! You can move forward with the rest of the form.
We are unable to verify your identity at this time. Please click 'Choose File' below to upload a photo of a valid ID with your name, or Contact Customer Service at 888-588-8094.
Upload Photo ID
Accepted file types: jpg, png.
Identity Verification Status
- Verifying
- Verified
- Denied
- Cannot Verify
- Start
- Skip/Flag Verification
Error Message
Identity Question Counter
First Page Pass/Fail
- Pass
- Fail

Doctor's Information
By providing your doctor’s information we can obtain approval to get your prescription delivered to you.
Please search for your Doctor using the fields below.
Please select your Doctor from the list and click This Is My Doctor below. If your Doctor is not listed, Search Again, or click Cannot Find My Doctor.
No Results Found? Click Search Again to keep searching, or click Cannot Find My Doctor to Enter Their Information
Please enter all of your Doctor’s Information including their phone number found on your most recent medication. When finished click Next at the bottom.
Search Type
- search
- manual
- result
- confirmed
Results Found
- Yes
- No
- Empty
Select Your Doctor Here:
Doctor's First Name
Doctor's Last Name
Office Location City
Office Location State
Office Location Zip
Doctor's Phone Number*
Alternate Doctor's Phone Number
Thank you. Please enter your Doctor's Phone Number found on your most recent medication if it is not the same as the one listed below and please click next.
NPI Number
NNPES Full Name
NNPES Address Street
NNPES Address City State
NNPES Phone Number
NNPES Fax Number

Thank you for providing your Doctor's Information. If we have any questions regarding their information we will contact you.
Thank You! The next step involves finding a Doctor right for you.
Disposition Date

Please list all medications you are currently taking, including both prescription and over-the-counter medications.*
Please list any serious illnesses you currently have or have had in the past.*
Please list any current allergies you have or have had in the past.*
For none enter none.

I hereby waive pharmacist counseling at this time. I understand that if I have any questions, a pharmacist is available for consultation.*
I understand
Did you answer all medical questions truthfully?*
- Yes
- No
We will need to go back and fix your answers, do recall which questions were untruthful?

Great! Just click SUBMIT and we're all set.
We are almost done. We pay for the doctor visit but we do collect payment information now so once they approve we can ship you out immediately. You will not be charged until you are approved.
Credit Card Number
Expiration Date
The expiration date?
And is the billing address the same as the shipping address? if not collect billing address.
Billing Address
Billing Address is the same as Shipping

Street Address City State Zip Code
Audio States (CA, HI, IL, IN, IA, KS, KY, LA, MD, MA, MI, MS, MT, NJ, OH, OK, OR, PA, RI, SD, TX, UT, VA, WY)
The doctor will be calling you confirm you are wanting this medication and if they have any more questions. Be on the lookout from a phone call coming from a Utah or Arizona area code.
Video State (AL, AZ, AR, DE, MO, ID, NV, NH, NM, VT, WV)
You will need to complete a video conference required by your state laws. We will have a support specialist contact you to give you login information and schedule the conference.
Digital States (CO, CT, FL, GA, ME, MO, NE, NY, TN, WA, WI)
Rarely the Doctor will call to confirm you are wanting this medication and if they have any more questions. If you get a call from a Utah or Arizona area code, answer it just in case.
Once we have the approval from the Dr we will bill your CC and get your medication shipped out. If you have any further questions. Please feel free to contact us at 1-888-588-8094
Payment Saved
Beluga Patient Upload
- success
- fail
- start
- skip
Now the last step is submitting your patient information to our provider. Please click the 'Submit Patient Info' button below.
Great! Now just click submit and we are all finished!
There was an issue submitting your information. Please try clicking 'Submit Patient Info' again.
Thank You! Now just click submit and we are all finished!
Beluga Raw Request Submission
Form Pass Fail
- pass
- fail

Phone*

Please verify your name here

What’s the address where you’d like me to send the medication to? Can I have your street address please?

Please make sure a valid State is entered

Unfortunately we cannot ship this prescription to this address. Please select a different prescription or enter a different valid Shipping Address. You may also choose to Use your Primary Care/Urologist or contact us for assistance at 888-588-8094.

We just need to validate your phone number before we can send you messages. Please click 'Validate Phone #' below.

Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number or a different contact method.

Thank you for verifying your number!

Identity Verification

Please click the 'Start Verification' button to begin the process. If necessary we may need to ask a few questions just to verify your identity.

We do not have enough information to verify your Identity. Please make sure all fields are filled in above and click 'Start Verification' again.

We were not able to verify your Identity. Please double check your information then click 'Start Verification' again.

Thank you for verifying your Identity! You can move forward with the rest of the form.

We are unable to verify your identity at this time. Please click 'Choose File' below to upload a photo of a valid ID with your name, or Contact Customer Service at 888-588-8094.

Doctor's Information

Please search for your Doctor using the fields below.

Please select your Doctor from the list and click This Is My Doctor below. If your Doctor is not listed, Search Again, or click Cannot Find My Doctor.

No Results Found? Click Search Again to keep searching, or click Cannot Find My Doctor to Enter Their Information

Please enter all of your Doctor’s Information including their phone number found on your most recent medication. When finished click Next at the bottom.

Thank you. Please enter your Doctor's Phone Number found on your most recent medication if it is not the same as the one listed below and please click next.

Thank you for providing your Doctor's Information. If we have any questions regarding their information we will contact you.

Thank You! The next step involves finding a Doctor right for you.

Questionnaire

In order to receive your prescription your Telemedicine Doctor will only contact you through Text messages. Do you wish to use the phone number provided earlier or use a different phone number to receive SMS/Text Messages?

Please click 'Validate Phone #' below to verify that we can send SMS/Text Messages to this number.

Please enter your phone number to receive SMS/Text Messages below and then click 'Validate Phone #'

Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number.

Sorry! We cannot send texts or multimedia messages to this Number. Please try a different number.

Thank you for verifying your number!

Thank you for answering our questions! You may go back to review your answers or click 'Next' to complete the rest of the form.

Thank you! You may go back to review your answers or click 'Next' to complete the rest of the form.

Questionnaire

Viagra

Cialis

Levitra

Stendra

Great! Just click SUBMIT and we're all set.

Now the last step is submitting your patient information to our provider. Please click the 'Submit Patient Info' button below.

Great! Now just click submit and we are all finished!

There was an issue submitting your information. Please try clicking 'Submit Patient Info' again.

Thank You! Now just click submit and we are all finished!