Zerviate 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 Zerviate 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 Zerviate 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 Zerviate Survey | Zerviate

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

Step 7Telemedicine Zerviate 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 Zerviate 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 Zerviate 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 Zerviate Survey | Zerviate
Q1.Last ophthalmologist exam? *
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Q2.Do you wear contacts? *
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Q3.Will you be driving or operating heavy machinery, and if so, when? *
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Q4.Are you having blurry vision or ocular discharge? *
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Q5.What is the specific allergy you have to medications? *
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Telemedicine Zerviate 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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