Skip The Sick. 🔒 We guarantee 100% privacy. Your information will not be shared with anyone. Get Ready to Build Your Custom Compounded Prescription Pack Step 1 of 3 33% Ready to See If a Compounded Therapy Is Right for You? Patient Information Takes Under 2 MinutesPatient Name* First Last Patient Email* Patient Phone*Terms & Consent* I agree to the Terms & Telehealth Consent Date of Birth using this format: (MM/DD/YYYY)* Month Day Year Gender*Select GenderMaleFemalePatient Height*Patient Weight (in pounds)*State (Select Texas OR Florida)*TXFLAllergies to Medications (if no known allergies to medications, type "NONE")* Let's Gather Your Medical History _________________________________________Medical History Checklist. Check ALL that apply.* Type 2 Diabetes High Blood Pressure High Cholesterol History of Thyroid Cancer or MEN2 History of Pancreatitis Gallbladder Disease Pregnancy or Breastfeeding Major Kidney or Liver Disease Other None of These Current Medications You Are Taking*Have you ever taken semaglutide, tirzepatide, NAD+, or glutathione?* Yes No I understand compounded medications, if prescribed, will be prepared and billed separately by Strive Pharmacy.* Yes I understand I must complete follow-up visits at least every 6 months to continue any compounded prescriptions.* Yes _________________________________________CONFIRM THAT YOU UNDERSTAND THAT THE TELEMEDICINE VISIT IS $XX* Joe Pill® Prescription Telemedicine Visit $XX (Required) Your Billing AddressBilling Address* Street Address Address Line 2 (optional) City ZIP Code Is your billing address the same as your shipping address?* Yes No Shipping Address* Street Address Address Line 2 (optional) City ZIP Code How did you hear about Joe Pill®?* Search engine (Google/Yahoo/Etc) Facebook/Instagram Tiktok Recommended by friend/colleague Total $0.00 Credit Card American ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Month010203040506070809101112 Year20252026202720282029203020312032203320342035203620372038203920402041204220432044 Expiration Date Security Code Cardholder Name After hitting SUBMIT below, a Joe Pill© affiliated telemedicine provider will review your submission and contact you by phone within 24 hours. Upon prescriber approval, your custom compounded medications will be mailed to you.CAPTCHA
