Get Your Prescription From Smart Health Pharmacy Name Email Sex Male Female Date Of Birth Phone Address State Zip Code Past Medical Problems (e.g. Asthma - if none, type "none") Current Medications (If none, Type "none") Known Allergies (If none, type "none") Medication Desired Dosage Desired Reason For Medication (Summarized) Does The Patient Have Personal Or Family History Of thyroid Cancer? Yes No Has the patient or a family member been diagnosed with Multiple Endocrine Neoplasia syndrome? Yes No Has the patient ever had an allergic reaction to Ozempic, semaglutide, Rybelsus, or another GLP-1 receptor agonist medication? Yes No Confirm 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
