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Page 1 of 3. Patient Information
Patient Name*
First Last
Patient Email*
Patient Phone*
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.
Date of Birth using this format: (MM/DD/YYYY)*
Month
Day
Year
Gender*
State (Select Texas OR Florida)*
Allergies to Medications (if no known allergies to medications, type "NONE". Telemedicine provider will adjust your preventive care pack if allergies exist)*

FINAL PAGE 3 of 3. Enter Shipping/Billing Information
Billing 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 Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number 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. After your telemedicine visit is complete, your preventive care pack will be mailed to you.
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