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Request 1 year supply of medications today!
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
- E
mail us at
RX@onthegopharma.com
- Call 602-607-5094. Leave us a message and we will call you back
Streamlined forms for Common Requests:
Bridge Supply
No insurance
in-between insurance companies
in-between health care provider
just want to save money on prescriptions (HSA & FSA eligible)
DoxyPEP
(Sexual Health)
Women's Health UTI
Men's Health Erectile Dysfunction (ED)
STD/STID/Herpes treatment or outbreak
(Sexual Health)
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Email
*
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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MM
/
DD
/
YYYY
Phone number
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Your answer
Shipping Address: What is your house number and street name? IE. 123 W Main Street APT B
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Your answer
Shipping Address: City
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Your answer
Shipping Address: State
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AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Shipping Address: Zip Code
*
Your answer
Do you have any allergies? If NO, leave blank
Your answer
What medications are you currently taking?
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Your answer
Would you like to request 1 Year supply on all of these medications?
*
Yes
No
Other:
Do you have any health conditions? If NO, leave blank
Heart Disease
Diabetes
High Blood Pressure
Asthma or COPD
Cancer - Type of Cancer:
Thyroid Problems
Kidney Disease
Mental Health Disorders
Other:
What is your Primary Care Doctors Name (PCP)?
*
Your answer
When was your last Doctor's Visit to your PCP?
*
Your answer
Have you had any recent hospitalizations or surgeries?
*
Your answer
Is there anything else you would like your healthcare provider to know?
*
Your answer
Consent and Acknowledgment
I consent to receiving telemedicine services and understand the nature of these services.
I acknowledge that my information will be used for the purpose of my telemedicine consultation.
*
I agree
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