Step 1 of 3: Personal Information

Please review your pre-filled personal details below. Contact your care team if anything looks incorrect.

First Name

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Last Name

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Date of Birth

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Gender Assigned at Birth

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Medication Requested

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Step 2 of 3: Medical Questionnaire

Review your pre-filled medical information. Contact your care team if any answers need updating.

Section 1: Medical History

Do you currently have any diagnosed medical conditions? —

Have you ever been hospitalized or undergone surgery? —

History of conditions None indicated

Section 2: Current Medications

Currently taking any prescription medications? —

Taking any OTC medications, vitamins, or supplements? —

Section 3: Allergies

Do you have any known allergies? —

Section 4: Lifestyle Information

Do you smoke or use tobacco products? —

Do you consume alcohol? —

Do you use recreational drugs? —

Are you currently pregnant, planning pregnancy, or breastfeeding? —

Section 5: Safety Screening

Adverse reactions to medications in the past? —

Ever been advised not to take certain medications? —

History of substance abuse or dependency? —

Have you recently experienced:

Chest pain? —

Shortness of breath? —

Severe allergic reaction? —

Thoughts of self-harm? —