Valtrex Prescription Request


Complete The Form

Complete the short form below.

Doctor Review

A US based medical professional will evaluate everything and follow up with questions.

Product Delivery

1-3 day shipping, discreet packaging and no signature needed.

Step 1Personal Details

Please fill out your personal details to speak with an MD. All personal details are stored in a secure HIPAA compliant manner.

Step 2Personal Details

Please fill out your personal details to speak with an MD. All personal details are stored in a secure HIPAA compliant manner.

Step 4Telemedicine Valtrex Survey | Telemed Acknowledgement

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 5Telemedicine Valtrex Survey | General

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Example: 190 (numerical only in pounds)

Step 6Telemedicine Valtrex Survey | Valtrex

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 7Telemedicine Valtrex Survey | Pharmacy Request

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Final Step Please Review before Submission


Personal Information
What is your Language ? *
First Name *
Middle Name
Last Name *
Gender
Street Address *
City *
State *
ZIP *
Date of Birth *
Phone Number *
Best Time to call you *
Email

Telemedicine Valtrex Survey | Telemed Acknowledgement
Q1.By checking this box and requesting an appointment, you will be provided the opportunity to consult with a physician that is licensed in your state of residence. This does not guarantee that the requested medications will be prescribed. We rely on the experience and medical knowledge of our highly qualified physicians to provide the best patient care possible through telemedicine. *
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Telemedicine Valtrex Survey | General
Q1.What is your chief complaint? *
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Q2.What is your Height: *
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Q3.What is your weight: *
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Q4.What current medications are you taking? *
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Q5.Are you Diabetic? *
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Q6.Do you take oral or insulin to treat diabetes? *
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Q7.Do you have any allergies: *
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Q8.Are you allergic to any medication? *
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Q9.Have you seen doctor in last 12 months: *
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Q10.Have you recently experienced a cough or allergy symptoms? Such as runny nose, itchy eyes, or scratchy throat? *
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Q11.Do you experience Seasonal Allergies? *
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Q12.Do you often feel sluggish, lack energy, or get frequent colds or flu? *
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Q13.Do you have chronic heartburn or acid reflux? *
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Telemedicine Valtrex Survey | Valtrex
Q1.Any history of other STDs? *
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Q2.When were you last screened for HIV, syphilis? *
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Q3.What is your sexual history, number of partners? *
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Q4.3. What is your sexual history, use of protection? *
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Q5.How many outbreaks do you have in a year? *
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Q6.Any specific triggers for outbreak? *
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Telemedicine Valtrex Survey | Pharmacy Request
Q1.If available, would you like your prescription delivered directly to your home? *
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Q2.If auto ship is an option for your medication would you be interested in enrolling in this option? *
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Q3.Pharmacy Lookup *
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