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Electronic Medical Consultation

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.
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)

Medical Information

Why do you need refills? *

What is the diagnosis/ reason for taking this medication? *

How long have you been on this medication? *

When was this medication last filled? *

Name of Physician who last filled medication. *

Pharmacy name and phone number where prescription was last filled? *

Upload Attachments

Upload a picture of the medication bottle showing the medication name and your name for faster service.

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

Amount: $65

Total: $65

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Card CVV

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