Medication Referral Fee

$ 100.00

Our doctors offer a positive consultation through phone or email.  The doctor will discuss your positive result, and how to correctly treat it.   Once contacted by the doctor, a prescription will be called into a pharmacy you choose. 

To receive treatment through one of our doctors, please copy the information below, paste it in a reply to this email and fill in the form below completely then return to-  


***There is a $100 fee for our doctors' consultation***

***This covers the consultation, the medication is paid for at the pharmacy*** 

***It can take up to 3 days for our doctor to contact you***


Patient Information

Patient Name: 
Date of Birth: 
Phone Number: 
OK to leave Phone Message -Y/N
Email Address: 
OK to Email Treatment Plan - Y/N
Race or Ethnicity: 
Test Date: 
Requesting Treatment For: 
Medical History
Drug Allergies: 
Current Medications: 
Previous Surgeries: 
Medical Conditions: 
Anything about your health the Physician needs to know: 
Pharmacy Information
Pharmacy Name: 
Phone Number:

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