Nexletol Prescription Request Page

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Your Selected Pharmacy

2. Patient Information

First Name

Last Name

Confirm Email

Sex

Female

Male

Birth Date

Phone

Address (Line 1)

Address (Line 2)

City

State

Zip Code

3. Patient Health Information

Secure Payment Pre-Authorization

Secure Payment

Thank you for submitting your request. We are pre-authorizing payment. The pre-authorization will show as a pending charge that will only settle if a medical provider provides a consultation and care recommendation. Your payment information is not saved.

Total Fees: $

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4. Confirm Request and Agree to Terms

After you submit your request, a licensed medical provider in your area will review your information. You will be notified by email when that provider has reviewed your request and, if appropriate, made care recommendations.

By checking this box, you indicate that you, as the patient or legal guardian of the patient, agree to the Terms of Service, Privacy Policy and Consent to Telehealth.

Name:
Birth Date:
Age:
Sex:
Email:
Phone:
Address:
Request:
Pharmacy:

Request Care in 4 Easy Steps

Pre-Authorize Payment of Virtual Consult Fees

1. Choose Pharmacy

2. Patient Information

3. Patient Health Information

Secure Payment Pre-Authorization

4. Confirm Request and Agree to Terms