HealthSource Pharmacy

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

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