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    Passthrough Fields

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    Phone*

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    What would be your preferred contact method for us or even the Doctor to be able to contact you if necessary?
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    You consent to being treated via telemedicine and being contacted via email, phone, or text. For more details regarding this consent you can visit dev.mydrhank.com
    Telemedicine Privacy Policy
    Telemedicine Informed Consent
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    Please verify your name here
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    Address, Phone verification

  • 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.
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  • MM slash DD slash YYYY
    Must be 18 years or older
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  • 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.

  • Accepted file types: jpg, png, Max. file size: 128 MB.
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  • 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.
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  • 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.
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  • 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.

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  • Now we're going to get into the clinical questions for your doctor.
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    ED Beluga Questionnaire

  • You need to know your blood pressure (BP) within the last year to receive treatment. It is an important factor in deciding whether it is safe for you to use ED medication. It is essential that you are accurate and honest about your BP. When used improperly these medications can cause serious harm, or death. Do not proceed if you do not know your BP.
  • BP is read as 2 numbers - the top number is ALWAYS higher than the bottom number. Example: 115/72 115 (systolic/top number) 72 (diastolic/bottom number)
  • Include any medicines (e.g. Lipitor, Zyrtec, Ibuprofen) or any supplement taken in the past 2 weeks, even if you are not taking them daily.)
  • Include any allergies to food, dyes, prescriptions or over the counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements or anything else.
  • How is your diabetes currently being treated? What is your average daily blood sugar? What is your last HA1C and how long ago was that?
  • Severe reactions may result if ED meds are used in conjunction with recreational drugs.
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    Pinkcream Beluga Questionnaire

    You need to know your blood pressure (BP) within the last year to receive treatment. It is an important factor in deciding whether it is safe for you to use this medication. It is essential that you are accurate and honest about your BP. When used improperly these medications can cause serious harm, or death. Do not proceed if you do not know your BP.
  • BP is read as 2 numbers - the top number is ALWAYS higher than the bottom number. Example: 115/72 115 (systolic/top number) 72 (diastolic/bottom number)
  • Include any medicines (e.g. Lipitor, Zyrtec, Ibuprofen) or any supplement taken in the past 2 weeks, even if you are not taking them daily.)
    Include any allergies to food, dyes, prescriptions or over the counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements or anything else.
    Severe reactions may result if these meds are used in conjunction with recreational drugs.
  • How frequently do you use them? When was the last time you used them?
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    Weight Loss Beluga Questionnaire

  • Please input your height in Feet and Inches, and your weight in pounds (lb). We will then calculate your BMI before you proceed. If your BMI is less than 27, you may not be eligible for treatment with us.
  • Please enter a number from 1 to 10.
  • Please enter a number from 1 to 12.
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  • Please enter a number from 10 to 1000.
  • We're sorry but your body mass index is too low for the doctor to be able to prescribe you Semaglutide. Please call us at 1-888-588-8094 for any additional questions.
    What is your biological gender?
    Include any allergies to food, dyes, prescriptions or over the counter medicines (e.g. antibiotics, allergy medications), herbs, vitamins, supplements or anything else.
    Select all that apply.
    Select all that apply.
    Select all that apply.
    Select all that apply.
    Select all that apply.
    Examples include liraglutide (Saxenda/Victoza), semaglutide (Wegovy/Ozempic), and dulaglutide (Trulicity).
    Select all that apply.
  • Include any medicines (e.g. Lipitor, Zyrtec, Ibuprofen) or any supplement taken in the past 2 weeks, even if you are not taking them daily.)
  • We are sorry but you are not eligible to be prescribed at this time. If you have further questions, please call us at 1-888-588-8094
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    PE Beluga Questionnaire

  • This includes medications prescribed (including other SSRIs), behavioral modifications, supplements or medications purchased over the counter or online, or other treatments.
    Select all that apply.
  • BP is read as 2 numbers - the top number is ALWAYS higher than the bottom number. Example: 115/72 115 (systolic) 72 (diastolic)
    Select all that apply.
  • Include if your condition is current or you have a history of this condition.
  • Select all that apply.
  • Select all that apply.
  • Select all that apply.
  • Please select all that apply.
  • Please select all that apply.
  • Please list the name and dose of each.
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    Phone verification non text preference

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  • 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?

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  • 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!

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    Beluga Submission

  • 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.

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    ED UpScript Questionnaire

  • Can I have your Height?
  • Can I have your weight?
  • Viagra

  • Cialis

  • Levitra

  • Stendra

  • For none enter none.
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    Final Checks

  • We will need to go back and fix your answers, do recall which questions were untruthful?
  • Payment Info

  • $0.00
    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.
  • And is the billing address the same as the shipping address

  • 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

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    Beluga Submission Confirmation

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Disclaimer

This is not medical advice. You and your physician will determine if (and potentially how) you should take Sildenafil or Tadalafil.

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