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Request Treatment for UTI
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:
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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
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Email
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Your email
What is your FIRST and LAST name?
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Your answer
What is your Date of Birth? (Payground, our payment processor, is going to ask for your Date of Birth to make payment )
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Phone number
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Shipping Address: What is your house number and street name? IE. 123 W Main Street APT B
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Shipping Address: City
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Shipping Address: State
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Shipping Address: Zip Code
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Do you have any allergies? If NO, leave blank
Your answer
Do you have any health conditions? If NO, leave blank
Your answer
List any medications you are currently taking (including non-prescription drugs and supplements):
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Your answer
What is your Primary Care Doctors Name (PCP)?
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Your answer
When was your last Doctor's Visit to your PCP?
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Your answer
Are you requesting a prescription for anything else?
COVID Request here
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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:
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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?
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Your answer
Have you experienced similar symptoms in the past?
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Yes
No
Do you have a history of urinary tract infections (UTIs)?
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Yes
No
Have you had any recent hospitalizations or surgeries?
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Your answer
Is there anything else you would like your healthcare provider to know?
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Your answer
Please describe your typical daily fluid intake and types of beverages
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Your answer
Do you have a history of bladder or kidney issues?
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Yes
No
Describe any recent changes in lifestyle or stress levels that might affect your health:
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Your answer
Would you like to request a prescription for any other types of medications?
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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.
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