Secure inquiry

Patient interest form

Share basic contact information and the areas you want reviewed. The care team will use it for initial routing and follow-up.

What are you interested in?

Choose at least one.

Informed Consent & Treatment Agreement

I acknowledge that any therapies prescribed through Med My Way LLC may include compounded medications, which are patient-specific preparations compounded by a licensed 503A pharmacy pursuant to a valid prescription. Compounded medications are not FDA-approved finished products, and safety and efficacy have not been evaluated by the FDA for these specific formulations.

I understand potential side effects, contraindications, and the need for ongoing lab and physician monitoring have been made available to me, and that treatment is dispensed only after a licensed physician determines it is medically appropriate based on my history and labs. I acknowledge that Med My Way LLC does not provide emergency care, and that I will call 911 for medical emergencies.

I understand government-issued ID verification and a state-compliant telehealth review are required prior to prescription issuance. I certify that all information I provide is accurate and complete to the best of my knowledge.

This form is for secure intake routing only. Keep the message focused and brief.