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Complete and electronically sign secure form below. You will be emailed confirmation the form was submitted properly.

Please call us at  833-543-3963 or click the online chat button if you require assistance 


Read all pages thoroughly. Answer all questions with as much detail as possible, including All of page three and top of page four (some people tend to skip over that).  

On the top line, right hand side next to Care Coordinator please   just type in “n/a”.   
When you send it you will then receive an e-mail from Right Signature asking you to confirm – click on that link in that e-mail and we will then 
receive the completed document.  Please also make sure your browser enables cookies, (Google Chrome can cause problems).
 

NO PRESCRIPTION WILL BE PROVIDED UNLESS A CLINICAL NEED EXISTS BASED ON REQUIRED LAB WORK, PHYSICIAN CONSULTATION, PHYSICAL EXAMINATION AND CURRENT
MEDICAL HISTORY. PLEASE NOTE, AGREEING TO LAB WORK AND PHYSICAL EXAM DOES NOT GUARANTEE A FINDING OF CLINICAL NECESSITY AND A PRESCRIPTION

No claim or opinion on the LifeXMD web-site is intended to be nor should it be construed to be, medical advice. Please consult with a healthcare professional before starting any therapeutic program. LifeXMD and it’s physicians do not carry malpractice insurance.

Privacy Policy:
LifeXMD realizes that customers are concerned about how the information they
provide online will be used. We are committed to protecting your privacy and will use the information we collect about you to process your order and provide a more personalized therapeutic experience.
LifeXMD will not rent, sell or exchange your name or other personally-identifiable information to third-party companies for their marketing purposes.