* Choose A Username

* Create A Strong Password (at least 12 characters, one Uppercase letter, one Lowercase letter, one Number, and one Special Character)

Strength: Very Weak

* Confirm Password (at least 12 characters, one Uppercase letter, one Lowercase letter, one Number, and one Special Character)

* Email Address

* First Name

Middle Name

* Last Name

* Phone Number in the format that includes country and area code e.g. "1XXXXXXXXXX"

Send SMS notification

* Date of Birth (MM/DD/YYYY) For example, December 25, 2021 is 12/25/2021

Race / Ethnicity - Please provide us with this information so that we can manage your care. Some drugs may have variable effects in different racial/ethnic groups.

* Biological Gender

Male

Female

* Are you currently pregnant?

Yes

No

If YES, when is your due date? (MM/DD/YYYY) For example, December 25, 2021 is 12/25/2021

* Do you have any allergies?

Yes

No

If YES, please list all allergies below:

* Preferred Language (e.g. English)

* Country / Region

* Address Line 1

Address Line 2

* City

* State / Region

* Zip / Postal Code

Were you referred by a friend? Enter their Name and Email Address below:

* Agree To The Terms

I Agree

By checking the box above, I am indicating that I agree to the Privacy Policy and Terms of Use of the Pill Pals website. In addition, I have read the Electronic Signature Consent Statement, HIPAA Authorization & Disclosure, and Disclaimer pages.

Text Message / SMS Consent

Sign me up for text alerts!

By checking this box and signing up for texts, you consent to receive text messages (e.g. account notifications and status reminders). Consent is not a condition of purchase. Msg & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP or clicking the unsubscribe button link (where available).

NOTE - Your One Time Passcode (OTP) will be sent to both your email and SMS Phone Number for your convenience