Top Health Center

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Date of Birth *

Email *

Phone Number *

Address *

Sex *
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Upload Past Medical Records *

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One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

1 - How often do you have oral herpes outbreaks?*

2 - Do you currently have or suspect an oral herpes outbreak?*

3 - Are you currently taking any of the following medications?*

4 - Have you tried any additional treatments in the past?*

5 - Was your past treatment effective?

6 - How often do you want to take your herpes medication?*

7 - Are you currently breastfeeding, currently pregnant, or may become pregnant?*

8 - Do any of these conditions apply to you?*

9 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

10 - Do you take any medicines, vitamins, or supplements?

11 - Please list any allergies you have.

12 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

13 - What type of treatment are you looking for? *

14 - "Do you have a preferred treatment? "*

15 - Do you have a preferred dose or strength?

16 - Do you have a preference on how often you'd like your medication?*

17 - Please enter preferred pharmacy information.*

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