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Before You Continue – Please Review Our Informed Consent Agreement

By continuing this process and clicking next below, you are indicating that you have read and agreed to our terms of use and privacy policy. These documents include information about relevant terms and conditions in detail. Some basics include:

In order to use our site, you must be 18 years of age or older, and by continuing this process and clicking next below, you affirm that you are at least 18 years of age.
Additionally, you acknowledge that you understand you’re engaging in an online medical consultation and that you hereby consent to receive healthcare services from one of our medical providers (MD, PA, NP, or DO).
You understand that our healthcare providers reserve the right to deny care for any reason.
You acknowledge that you have a complete understanding of the risks and advantages associated with online medical consultations.

Basic Information

Consultation Name

First Name*

Last Name*

Email*

Phone Number*

Preferred Mode of Communication?*

Text
Phone Call
Email

Date of Birth*

Address*

Zip Code*

Select Your State*

City*

Gender*

Male
Female
Transgender (M to F)
Transgender (F to M)

Please Upload a Copy of Your Driver's License or State ID

Pharmacy Info to Pick Up Prescription

Pharmacy Name*

Pharmacy Phone Number*

Pharmacy Address*

Pharmacy Zip Code*

Pharmacy State*

Pharmacy City*

How Do You Plan to Pay for Prescription?*

Cash
Medical Insurance

How Did You Find Us?*

Important

Payment made to us does NOT include the pharmacy charge. You still have to pay for the medicine at your pharmacy with your insurance card or out of pocket

Notify us immediately with any prescription-related issues at prescription@fastdocnow.com

Secure Payment

Card Number

Expiration Month

Expiration Year

CVV

Billing First Name

Billing Last Name

Billing Address

Billing Zip Code

Billing State

Billing City

Amount $39

Promotional Code?

Apply Coupon

Total $39

Consultation Booking

Electronic Medical Consultation