ED Intake
Take the First Step Toward Regaining Confidence
Welcome to the ED Intake Form. At Peak Family Health, we prioritize your health and privacy. This form marks the first step in our simple and secure process to help address your concerns. By completing the intake, you’ll provide us with the essential details we need to understand your needs and begin creating a personalized treatment plan tailored to you. Rest assured, your information is handled with the utmost confidentiality, and our team is here to support you every step of the way.
Read the instructions below and complete the form at the bottom of the page. Our provider will review your form and quickly reach back out to you.
Step 1: ED Consultation Intake
The process begins with a brief ED Consultation Intake Form, where you’ll provide basic information about yourself and your reason for seeking care. This is a quick and asynchronous (not in-person) process, allowing you to complete it at your convenience.
- Cost: $65, payable at the time of submission.
- What happens next: Our provider reviews your submission to ensure a successful payment. Upon approval, you’ll receive a Patient Medical Intake Form via email (if you’re a new or returning patient without updated information).
Step 2: Medical Intake and Review
Once you’ve completed and submitted the Patient Medical Intake Form, our provider will:
- Review your information to better understand your medical history and health needs.
- We recommend and prescribe the appropriate ED medication, then communicate the plan through your secure Patient Medical Portal. Instructions for accessing the portal are included in the email.
Prescription Fulfillment
We process and send medications to the pharmacy of your choice, as indicated on your Medical Intake Form. You have the option to select your local pharmacy or opt for our partnered mail-order compounding pharmacy, MediveraRx, which offers discreet and cost-effective services. Detailed charts outlining medication and shipping costs for MediveraRx Pharmacy are available. Follow-ups and refills can be efficiently managed through the secure Patient Medical Portal, ensuring you receive convenient and confidential ongoing care.
| Medicine | Price p/Pill | Quantity | Total Price |
|---|---|---|---|
| Sildenafil 20 mg | $1 | 30 | $30.00 |
| Sildenafil 25 mg | $1 | 30 | $30.00 |
| Sildenafil 50 mg | $2 | 15 | $30.00 |
| Sildenafil 100 mg | $4 | 10 | $40.00 |
| Tadalafil 5 mg | $1 | 30 | $30.00 |
| Tadalafil 10 mg | $2 | 15 | $30.00 |
| Tadalafil 20 mg | $3 | 10 | $30.00 |
| Vardenafil 5 mg | $8 | 4 | $32.00 |
| Vardenafil 10 mg | $9 | 4 | $36.00 |
| Vardenafil 20 mg | $10 | 3 | $30.00 |