dawn | Joe Pill

PATIENT INFORMATION
Let'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*
State (service only available for Texas or Florida residents)*
Allergies to Medications (if no allergies to medications, type "NONE")*
Patient Email*
Patient Phone*
I am seeking treatment for the following:*
Billing Address*
Street Address Address Line 2 (optional) City 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 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.

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.