Joe Pill® Appointment Information PATIENT INFORMATIONLet's get started... Before we gather your patient information, please click below to agree to the Joe Pill® Terms & Conditions, Privacy Policy and Telehealth Consent:* Yes, I agree to the Joe Pill® Terms & Conditions, Privacy Policy, and Telehealth Consent and I can confirm that I am a resident of either Texas or Florida. Patient Name* First Last Date of Birth using this format: (yyyy/mm/dd)* Year Month Day Gender*Select GenderMaleFemaleOtherState (service only available for Texas or Florida residents)*TXFLAllergies to Medications (if no allergies to medications, type "NONE")*Patient Email* Patient Phone*I confirm that I am seeking a Joe Pill® Prescription Pack™* Yes, I want a Joe Pill® Prescription Pack™ and understand the cost is $149 for the basic pack. I confirm that I am also interested in the following "add-ons" to my travel pack and understand there is an additional cost to add the items below.* Sea Sickness Transdermal Scopolamine Patches ($36 for quantity 3 72-hour patches) Itchy Rash / Insect Bite Triamcinolone 0.1% Cream 30grams ($12) Gout Attack Indomethacin 50mg 20 capsules ($12) Romantic Getaway Viagra® (sildenafil) 100mg 30 tablets ($25) Cold Sore Package: Valtrex® (valacyclovir) tablets PLUS travel size acyclovir cream ($39) Extra Zpak? Only $9 Extra Medrol Dose Pack? Only $12 No "Add-ons" Are Desired At This Time Billing Address* Street Address Address Line 2 (optional) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Texas or Florida ZIP Code Is your billing address the same as your shipping address?* Yes No Shipping Address (only available in Texas or Florida)* Street Address Address Line 2 (optional) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Texas or Florida ZIP Code After hitting SUBMIT below, a Joe Pill® affiliated licensed provider will contact you by phone within 24-48 hours. If approved by a medical provider, prescriptions will be sent by mail promptly upon full payment.
