MyDrHank Intake — MyDrHank

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Passthrough Fields
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Active Stage
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Form
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Current Page
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Last page
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Full Intake Progress
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Total Duplicates
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Product
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Visit Id
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Verification Id
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Status
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Tags
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time_zone
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Stage
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Disposition
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Visit ID
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phone_primary*
Phone*
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Email Address
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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
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Teledoc Option*
- Use my doctor.
- Help me find a doctor.
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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 dev.mydrhank.com
Telemedicine Privacy Policy
Telemedicine Informed Consent
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Product Name
- SILD 20 mg x 25 tablets for $47.50
- SILD 20 mg x 50 tablets for $90
- SILD 50 mg x 10 tablets for $50
- SILD 50 mg x 20 tablets for $95
- SILD 100 mg x 5 tablets for $50
- SILD 100 mg x 10 tablets for $95
- SILD 100 mg x 20 tablets for $125
- SILD 100 mg x 30 tablets for $150
- TADA 5 mg x 30 tablets for $75
- TADA 10 mg x 5 tablets for $30
- TADA 10 mg x 10 tablets for $55
- TADA 10 mg x 25 tablets for $125
- TADA 20 mg x 5 tablets for $50
- TADA 20 mg x 10 tablets for $95
- TADA 20 mg x 20 tablets for $125
- TADA 20 mg x 30 tablets for $150
- Troche 12 doses for $60
- Troche 20 doses for $95
- Troche 40 doses for $150
- Paroxetine - 20 mg x 30 tablets for $49.99
- Sertraline - 50 mg x 30 tablets for $49.99
- Pink Cream 15gm for $45
- Semaglutide 5ml for $295
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drug_type
- SILD
- TADA
- TROCHE
- PE
- PINK
- WEIGHTLOSS
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odoo_frequency
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odoo_drug
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Hidden Size
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odoo_quantity
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odoo_subscription
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odoo_price
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Conditions
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Drugs
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Allergies
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Name*
Please verify your name here
First Name Last Name
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patient_submission_start_full_name
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First Name
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Last Name
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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?
Shipping Address*
Street Address City State Ex: FL or Florida ZIP / Postal Code Country
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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Hidden State
May I get your date of birth please?*
MM slash DD slash YYYY

Must be 18 years or older
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Hidden DOB
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DOB Pass Fail
- fail
- pass
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Doctor Selection Type
- Personal
- Beluga Health
- Upscript
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Phone Verification
- verified
- unverified
- start
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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, Max. file size: 128 MB.
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Identity Verification Status
- Verifying
- Verified
- Denied
- Cannot Verify
- Start
- Skip/Flag Verification
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Error Message
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Identity Question Counter
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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.
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Search Type
- search
- manual
- result
- confirmed
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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.
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NPI Number
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NNPES Full Name
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NNPES Address Street
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NNPES Address City State
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NNPES Phone Number
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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.
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Disposition Date

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Phone verification non text preference
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Second Phone Verification
- verified
- unverified
- start
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Second Phone Verification Pass/Fail
- pass
- fail
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Final Phone Verification Pass/Fail
- pass
- fail
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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SMS/Text Message Prompt
- I Consent to SMS/text message communication at my phone number provided
- I Consent to SMS/text message communication BUT wish to use a different number
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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Phone
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Verify/Re-enter Phone 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.

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.

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Final Checks
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?

Payment Info
Prescription Total
$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.
Credit Card Number*
Expiration Date*
And is the billing address the same as the shipping 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
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Payment Saved
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Beluga Submission Confirmation
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Beluga Raw Request Submission
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Form Pass Fail
- pass
- fail

Passthrough Fields

Phone*

Please verify your name here

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.

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.

ED Beluga Questionnaire

Pinkcream Beluga Questionnaire

Weight Loss Beluga Questionnaire

PE Beluga Questionnaire

Phone verification non text preference

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!

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.

ED UpScript Questionnaire

Viagra

Cialis

Levitra

Stendra

Final Checks

Payment Info

And is the billing address the same as the shipping address

Beluga Submission Confirmation