📍 9787 SW 72nd St, Miami • Open Mon–Fri 8:30 am–6:00 pm · Sat 9:00 am–1:00 pm • Free local delivery
Refill prescription → WhatsApp ES
Home/ Emergency Kits/ Prescription Intake
Telehealth intake

Start Your Order

Complete this form so a licensed Florida physician can review your health profile and authorize your kit medications. Most reviews are complete within 24 hours.

Step 1 — About you 1 of 4

About you

Your details and how to reach you. Fields marked * are required.

Must be a Florida address — §456.47 requires you to be in Florida during the consult.

Your health

Check anything that applies so the physician can screen for interactions. Leave the rest blank.

Health conditions
Drug allergies
Check any drug allergy — each one blocks a matching kit medication.
Medications
Safety screening

Consent & signature

Florida law requires your consent before a physician can review your intake.

Telehealth consent — §456.47. Telehealth delivers care through electronic communication; you will not be physically present with the provider, and in-person follow-up may be required. A Florida-licensed physician reviews your responses before any prescription is issued. Telehealth is not for emergencies — call 911 for anything life-threatening. You may withdraw consent at any time.

HIPAA privacy. Your protected health information is used for treatment, payment, and healthcare operations per our Notice of Privacy Practices. It is never sold or used for marketing without your written authorization.

Prescription acknowledgment. A prescription may or may not be issued, at the physician's discretion. Schedule II–V controlled substances cannot be prescribed via telehealth without a prior in-person examination.
Typing your name applies a legally binding e-signature (UETA / federal E-SIGN Act), dated today.

Delivery & review

How you'd like your kit, then a quick look before you submit.

Delivery preference
Emergency contact (optional)
Review

Your summary appears here.

Intake form submitted

A confirmation has been sent to your email. A Florida-licensed physician will review your responses and contact you within 1 business day.

If you are experiencing a medical emergency, call 911. This form does not constitute a physician-patient relationship until the reviewing physician accepts your case.

What to expect

  1. Submit this intake form — takes about 3 minutes.
  2. A Florida-licensed physician reviews your responses.
  3. We contact you within 1 business day to discuss your kit and authorize the prescription.
  4. We dispense and ship your kit directly from our Miami pharmacy.

Privacy & security

This form is transmitted over an encrypted (HTTPS) connection. Your health information is handled under HIPAA and Florida patient privacy law.

We verify your identity by phone before your kit is authorized — no ID number is collected on this form.

Questions?

Call or text our pharmacists directly — we're happy to walk you through the intake process.

(786) 558-0702 WhatsApp

Hours: Mon–Fri 8:30am–6pm, Sat 9am–1pm

Florida telehealth notice

This telehealth service operates under Florida Statute §456.47. The prescribing physician is licensed in Florida. Controlled substances (Schedule II–V) cannot be prescribed via telehealth without a prior in-person examination.

About this intake: Completing this form does not guarantee a prescription will be issued. All prescriptions are authorized by a licensed Florida physician following clinical review. This form is not a substitute for emergency medical care — call 911 in a life-threatening emergency. D&D Pharmacy is independently owned and licensed in Florida.