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 am seeking treatment for the following:*Prescription Travel Pack™ ($149)Cold Sore/Antiviral ($79)Erectile Dysfunction ($79)Billing Address* Street Address Address Line 2 (optional) City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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.