Request Treatment for UTI

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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

Questions:

- Chat with us here

- Text 602-607-5094

- Email us at RX@onthegopharma.com

- Call 602-607-5094. Leave us a message and we will call you back

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 )
*

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?

COVID Request here

Arthritis

Common Cold

Urinary Tract Infections

Sore Throat

Ear Infection

Muscle Sprain(s)

Skin infection

Burn

Abdominal Pain

Cough

Fever or chills

Shortness of breath or difficulty breathing - Ashtma - request rescue inhaler and/or nebulizer meds

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Congestion or runny nose

Nausea or vomiting

Diarrhea

High blood pressure

Diabetes management

Back pain

Skin concerns (e.g., rashes, acne)

Other:

Required

Please describe your current symptoms: *

Burning sensation during urination

Frequent urge to urinate

Cloudy or strong-smelling urine

Pelvic pain (in women)

Fever or chills (indicate a possible infection)

Required

When did you first notice these symptoms? *

Have you experienced similar symptoms in the past?
*

Yes

Do you have a history of urinary tract infections (UTIs)?
*

Yes

Have you had any recent hospitalizations or surgeries?
*

Is there anything else you would like your healthcare provider to know?
*

Please describe your typical daily fluid intake and types of beverages
*

Do you have a history of bladder or kidney issues?
*

Yes

Describe any recent changes in lifestyle or stress levels that might affect your health:
*

Would you like to request a prescription for any other types of medications? *

Azithromycin 250 mg tablets [Z PAK] antibiotic

Acyclovir

Valacyclovir (Valtrex)

No Thank you - I am good now, maybe later at another time

Other:

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.

I agree

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