Patient Intake

Home Patient Intake
  • Use this patient intake form for faster processing of new prescriptions.
  • Indicate your delivery preference and we’ll take care of the rest.
  • Enjoy the same security and confidentiality as you do for your in-store prescriptions.
  • We never share your personal information and abide by HIPPA privacy practices.

Patient Intake

    Your Doctor's Name:
    Your Name:
    Your Date of Birth:
    Your Cell Number (we will text you a status update):
    Your Email Address:
    Allergies (separated by commas):
    Vintage Labs Supplements:
    Shipping Preference:
    Shipping Address (no P.O. Boxes):
    Billing Address (if different from shipping address):
    Payment Type:
    Payment Information (name, card number, expiration date, CVC code):
    Additional Instructions or Comments (if applicable):

    If a single patient’s order exceeds $200 we will call you to confirm before we process the order. Otherwise, we will process the order immediately as per pricing on this page.

    Confirmation:
    Please help us eliminate spam by answering this question correctly:


    * We abide by HIPAA law and never share personal information.

    Ivermectin Pricing:
    (strength ranges 12-56 mg, filled as per Rx)
    • Up to 20 Tablets: $69.00
    • 21-30 Tablets: $98.00
    • 31-45 Tablets: $139.00
    • 46-60 Tablets: $169.00
    • 61-90 Tablets: $199.00

     

    Fluvoxamine Pricing:
    • 30 Tablets: $98.00

     

    Hydroxychloroquine Pricing:
    • 30 Tablets: $75.00

     

    Supplement Pricing:
    • Quercetin+ 500mg 120 Capsules: $54.95
    • Vitamin D 1000 IU 250 Tablets: $22.00
    • Vitamin D 5000 IU 100 Tablets: $28.89
    • Vitamin D 5000 IU + K 60 Tablets: $29.00
    • Vitamin D 10000 IU + K 60 Tablets: $35.99
    • Vitamin D 10000 (drops) 30ml: $29.95
    • N-Acetyl-Cystine (NAC) 120 Capsules: $38.95
    • Melatonin 3mg 60 Capsules: 23.00
    • Vitamin C 1000mg 90 Tablets: $39.00
    • Zinc+ 60 Capsules: $28.95

     

    Tracking numbers will be emailed to you upon shipping.

    Long Beach Location

    Mon – Fri 9AM – 8PM
    Saturday 9AM – 4PM
    Sunday 10AM – 3PM

    Need Additional Assistance? Contact Us Anytime!