Medication eligibility processBasic InformationFull name Full nameDate of Birth Date of BirthYour email Your emailPhone Number Phone Number Do you currently reside in the U.S.? Do you currently reside in the U.S.?YesNoHealth ScreeningDo you have a primary care provider or healthcare provider you regularly follow up with? Do you have a primary care provider or healthcare provider you regularly follow up with?YesNoAre you currently pregnant, planning to become pregnant, or breastfeeding? Are you currently pregnant, planning to become pregnant, or breastfeeding?YesNoN/ADo you have any known allergies to medications? Do you have any known allergies to medications?YesNoHave you been diagnosed with any of the following conditions? Have you been diagnosed with any of the following conditions? High blood pressureDiabetesHigh cholesterolDepression or anxietyThyroid disorderKidney diseaseLiver diseaseNone of the aboveHave you ever been hospitalized in the last 6 months? Have you ever been hospitalized in the last 6 months?YesNoMedication Specific QuestionsHas a licensed healthcare provider ever prescribed you Lisinopril or another blood pressure medication? Has a licensed healthcare provider ever prescribed you Lisinopril or another blood pressure medication?YesNoHave you experienced any side effects with Lisinopril (e.g., cough, swelling, dizziness)? Have you experienced any side effects with Lisinopril (e.g., cough, swelling, dizziness)?YesNoAre you currently taking any medications? Are you currently taking any medications?YesNoConsent & AttestationQuestion QuestionI confirm that all the information provided above is accurate to the best of my knowledge.I understand that this service is not a replacement for regular in-person medical care.I consent to have this information reviewed by a licensed healthcare provider for the purpose of approving or denying my access to purchase this medication.
