Joe Pill® Prescription Pack Approval Form SIMPLE ONE PAGE FORMLet's get started... Before we gather 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 am licensed to practice in Texas. Patient Name* First Last Date of Birth using this format: (yyyy/mm/dd)* Year Month Day Gender*Select GenderMaleFemaleOtherState (service only available for Texas residents)*TXAllergies to Medications (if no allergies to medications, type "NONE")*Patient Email* Patient Phone*Patient is seeking treatment for the following:*Joe Pill Prescription Pack™ ($149)Patient is also interested in "add-ons" for the prescription pack for an additional charge. Sea Sickness Transdermal Scopolamine Patches ($36 for qty 3 patches) Itchy Rash / Insect Bite Triamcinolone 0.1% Cream ($12) Gout Attack Indomethacin 50mg Capsules ($12) Romantic Getaway Sildenafil 100mg #30 Tablets ($25) Cold Sore Valacyclovir 1g tablets PLUS Travel Size Acyclovir Cream ($39) Extra Azithromycin Pack? Only $9 Extra Inflammation/Rash Dose Pack? Only $12 Albuterol Inhaler? Only $26 NO "add-ons" are desired at this time Patient Billing Address* Street Address Address Line 2 (optional) City ZIP Code Is patient billing address the same as your shipping address?* Yes No Patient Shipping Address (only available in Texas)* Street Address Address Line 2 (optional) City ZIP Code Prescriber Name Prescriber NPI Prescriber DEA# (For prescriber verification only, no controlled substances handled) Prescriber SignatureAfter hitting SUBMIT below, we will send an email with a secure link to the patient for payment. Approved prescriptions will be sent by mail promptly upon payment.
