General Medication Form – Smith Collective

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Contact
Treatments
About Us
Upload Script
Medication Form
Emergency Prescription
Nicotine
Login

Contact
Treatments
About Us
Upload Script
Medication Form
Emergency Prescription
Nicotine
Login

Contact
Treatments
About Us
Upload Script
Medication Form
Emergency Prescription
Nicotine
Login

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General Medication Form

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- Step 1 of 3

Patient Details *

First

Last

Mobile Phone *

Home Phone

Email *

Date of Birth *

Do If medicine

What type of medicine are you looking to order? *

Prescription or over-the-counter medication? *

Prescription
Over-the-Counter

Do you have a prescription for this medicine? *

Yes
No

What is the intended treatment? *

Which symptoms or conditions are you treating with this medication? *

Acute Pain
Anxiety
Arthritis
Autism
Auto Immune
Cancer
Chemo induced nausea and vomiting
Chronic Pain
Degenerative Disease
Depression
Dystonia
Epilepsy
Fibromyalgia
Insomnia
Loss of Appetite
Mental Health
Migraines
Movement Disorders
Multiple Sclerosis
Muscle Pain
Muscle Spasms
Nerve Pain
Neurological
Osteoarthritis
Pain Inflammation
Panic Attacks
Psoriasis
PTSD
Seizure Management

Are you currently taking any other medications or supplements? If yes, please list: *

Yes
No

Medications or Supplements *

Do you have any known allergies to medications? If yes, please list: *

Yes
No

Allergies *

Have you taken this medication before? *

Yes
No

Do you have any existing medical conditions? If yes, please list: *

Yes
No

Existing Medical Conditions *

Are you pregnant, nursing, or planning to become pregnant? *

Yes
No

Do you need any advice on how to take this medication? *

Yes
No

Would you like any information about potential side effects? *

Yes
No

Would you like to discuss any alternative treatments? *

Yes
No

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