Compound Medication Membership

1
Have you been diagnosed with hypothyroidism?* This field is required.
YESNO
2
Have you had thyroid cancer?* This field is required.
YESNO
3
What type of thyroid medication are you currently on?* This field is required.
T4 (eg. Levothyroxine or Synthroid)
T4 + T3 Combo
NDT (eg. Armour or Nature-throid)
Compounded formulation
I'm not currently taking medication
Other
4
How long have you been on this medication?* This field is required.
Less than a year
1-2 years
2+ years
5
How satisfied are you with your current medication?
1
2
3
4
5
6
7
8
9
10
Very Dissatisfied
Very Satisfied
6
How many other medication brands/formulations have you tried in the last 5 years?* This field is required.
7
What state are you in?* This field is required.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
8
How can we reach you when a spot is available?
example@example.com
9
Please allow us to place a hold on your credit card to save your spot on the waitlist. Your card will not be charged until after your first call with your care manager.
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Compound Thyroid Meds Membership
$45.00Edit
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