Pharma+ Protocol

Health Intake Form

Complete this form for physician review. A licensed physician will review your information within 24-48 hours and approve your prescription medications.

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Physician Review24-48 hours

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Your health information is encrypted and HIPAA-compliant. Only the reviewing physician will access your medical details.

Personal Information

First Name *

Last Name *

Date of Birth *

Biological Sex *

Email *

Phone *

State of Residence *

Weight (lbs) * Used for dosage calculation

Health History

What symptoms are you experiencing? *

How long have you had these symptoms?

Have you been tested for parasites? If so, what were the results?

Current medications (include dosages) *

Known allergies *

Check all that apply:

Liver disease or elevated liver enzymes Kidney disease Pregnant or planning to become pregnant Currently breastfeeding Taking blood thinners (Warfarin, Eliquis, etc.) Immunosuppressed or on immunosuppressive therapy History of seizures None of the above

Have you done a parasite cleanse before? If so, which protocol?

Anything else your physician should know?

Prescription Shipping Address

Rx medications ship separately from a licensed compounding pharmacy.

Street Address *

City *

ZIP Code *

Health Intake Form

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