Request Treatment for STI/STDS or DoxyPEP
  • Welcome to Your Path Towards Better Health with Doxypep
  • Please fill out this confidential intake form to help us understand your needs and health background better. Your journey to wellness starts here.


    • Questions: 
    - Text 602-607-5094
     - Email us at RX@onthegopharma.com
    - Call 602-607-5094. Leave us a message and we will call you back

    3 Easy Steps:

    1. Fill out Form 
    2. Pay via link in your email/text message once order approved (within 24 business hours)
    3. Meds Delivered directly to you


    Sign in to Google to save your progress. Learn more
    Email *
    What is your FIRST and LAST name? *
    What is your Date of Birth? (Payground, our payment processor, is going to ask for your Date of Birth to make payment )
     *
    MM
    /
    DD
    /
    YYYY
    Phone number *
    Shipping Address: What is your house number and street name? IE. 123 W Main Street APT B *
    Shipping Address: City *
    Shipping Address: State     *
    Shipping Address: Zip Code *
    Do you have any allergies? If NO, leave blank
    Do you have any health conditions? If NO, leave blank
    List any medications you are currently taking (including non-prescription drugs and supplements):  
     *
    What is your Primary Care Doctors Name (PCP)?  *
    When was your last Doctor's Visit to your PCP?  *
    Are you requesting  a prescription for anything else? *
    Required
    Briefly describe any symptoms  *
    Duration of symptoms (How long having you been having the symptoms)? *
    Have you had any recent hospitalizations or surgeries?  
     *
    Is there anything else you would like your healthcare provider to know?  
     *
    Describe your current lifestyle and any factors that may affect your health (e.g., dietary habits, exercise routine, stress levels):  
     *
    Would you like to request a prescription for any other types of medications?  *
     Consent and Acknowledgment
    I consent to the processing of my personal and health information for the purpose of evaluating and providing health-related recommendations. 

    I understand that my information will be kept confidential in accordance with privacy laws.
     *
    Submit
    Clear form
    Never submit passwords through Google Forms.
    This form was created inside of onthegopharma.com. Report Abuse
    Google Forms