Get Your Prescription From Simple Online Doctors Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Sex *MaleFemaleDate Of Birth *Phone *AddressState *Zip CodePast Medical Problems (e.g. Asthma - if none, type "none")Current Medications (If none, Type "none")Known Allergies (If none, type "none")Medication DesiredDosage DesiredReason For Medication (Summarized)Does The Patient Have Personal Or Family History Of thyroid Cancer?YESNOHas the patient or a family member been diagnosed with Multiple Endocrine Neoplasia syndrome?YESNOHas the patient ever had an allergic reaction to Ozempic, semaglutide, Rybelsus, or another GLP-1 receptor agonist medication?YESNOConfirm Request and Agree to Terms *By clicking the "Submit Request" button, 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.After you submit your request, a licensed medical provider will review your information. You will be notified by email when that provider has reviewed your request and, if appropriate, made care recommendations.Submit
