Hypothyroidism Medicine Refill

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Please enter the following information so we know if we have doctors available for you.
What state are you requesting treatment in? *

Sorry, but we don't have any doctors available in that state right now.

If you continue to fill out this form, we will not be able to complete your medication request. We are working hard to add more doctors to our team!

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Let us get to know you.

The following information is going to help us qualify you and give you the best treatment possible.
What is your Full Name? *

First NameMiddle Name (optional) Last Name
What is your phone number? *

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What is your Date of Birth? *

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Select your Sex, we'll make sure you qualify for this treatment.*

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Please enter your height (inches). *
Please enter your weight (lbs).*
What is your Address?*

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Is this also your billing address?*

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Hypothyroidism Medicine Refill

Please give us some more information so we can process your request and match you with a doctor.
What do you want us to help you with today? We can only refill levothyroxine (Synthroid) with this service. We do not fill Nature-Throid, Armour, or other thyroidhormones.*
What dose of levothyroxine (Synthroid) do you take?*
Do you take other medicines for your thyroid besides levothyroxine (Synthroid)?*

YesNo
What was your last TSH (thyroid stimulating hormone) level?*
When was your last thyroid level taken?*
When was your dose of levothyroxine (Synthroid) last adjusted?

What is the diagnosed cause of your hypothyroidism?*
Have you ever had any side effects from levothyroxine (Synthroid)? You should read thefull warnings with any medicine and let us know if you experience side effects.*

YesNoOther
What side effects did you have? *
What is the name and phone number of the doctor who wrote your last prescription for levothyroxine (Synthroid) medicine? We may need to verify your history of severe allergies with your previous provider.*
Is this your Primary Care Doctor?*

YesNo
Do you currently have a primary care doctor?*

YesNo
What is the name and Phone number of your primary care doctor? *

Checkout Time!

Once your payment is processed and the form is submitted a doctor will reach out to you shortly!
Hypothyroidism Medicine Refill*
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Hypothyroidism Medicine Refill
$0.10

Total

$0.00
Uploading a Photo of your ID will help us confirm your identity and make it easier for us to give you treatment. (Optional)

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