Brookshire Brothers #26

Patient Name -- (required)

Name (if different than patient name, i.e. parent or guardian)

Email

Phone Number

Patient Birthdate

Pharmacy Name

Pharmacy Fax #

State

Select your Telemedicine Kit
COVID-19FluStrepUTIAnemiaBirth ControlErectile Dysfunction

Symptoms Patient is Experiencing
COVID-19/Coronavirus symptomsSore throatFlu-like symptomsFatigueDiscomfort when urinatingErectile Dysfunction symptomsOther/none of the above

I agree to the Terms of Service and Privacy Policy. I understand the information I send will be sent to Physician 360.
YES

I certify that I have read and accept the terms of Physician 360's Informed Consent.
YES