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Upload Prescription
Upload Prescription
Full Name *
Email *
Phone Number *
Date of Birth
Patient Condition *
Select condition
Critical
Second choice
Third choice
Doctor’s Name
Special Instructions
Upload Prescription File
I confirm this is a valid prescription issued by a licensed U.S. physician.
Submit Prescription
Submit Prescription
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Note:
Webflow natively does not support prescription upload functionality (file uploads with HIPAA compliance). To enable prescription uploads, you’ll need to integrate with a third-party service or have an upgrade business plan.