MD Consult Detail - Prescriptive Optimization

SynapsinClioquinol

Compounded Product

First Name *

First

Last

Phone (Please put cell if you have one) *

Phone Type *

Email *

Date of Birth

must be 18+

Gender *

Male

Female

Address *

Address

City

State/Province

Zip/Postal

Country

Are You Under Care of another Doctor/Provider/Prescriber?

We will update your doctor about today's consult and prescription if you have one.

Primary Care Physician *

Phone

Doctor Fax Number

We need this to send a note, pls give a quick google search if you don't seem to have it by other means must be in this format 3606756688 no space punctuation or leading 1

Medication Allergies *

Medical Conditions *

Current Medications

To standardize Prostate symptoms, please FILL OUT THIS SURVEY, then do two things back here:

Input the IPSS Score, Symptom Severity, and Quality of Life Score in dedicated fields below
Copy the entire results using the button as shown here, and paste results in the text box below'

IPSS Score

Symptom Severity

Quality of Life Score

Full Results Box (Paste from QxMD

Product

Credit Card

For MD Consult & Securely transmitted to pharmacy for their payment at time of dispense

Total

Confirmation *

I certify the information herein is true, correct, and complete. I consent fully to have this medication prescribed, understanding it is compounded (made custom for me from scratch). I will seek all medical care from my established primary care provider - this interaction is narrowly focused to assess appropriateness for this medication only. Administration Questions should be directed to the pharmacist. I further authorize the approved prescription be transmitted to Island Drug in Oak Harbor. I have read my HIPAA rights at islanddrug.com/privacy

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