Intake - signal-rx

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Secure online intake

One $5 review. Choose your treatments.

Choose one or more treatments, then answer a few health questions. It takes about 5 minutes. No appointment or video call.

Provider review: $5paid once; A licensed provider reviews each treatment you choose.
Medication: Separate; Pay only if medication is prescribed and ordered.

What happens next

Choose treatments
Answer health questions
Provider review

No membership or subscription
No automatic refills or shipments
No second $5 review fee

The $5 provider-review fee is nonrefundable. A prescription is not guaranteed. Each medication has its own price.

Which treatments are you interested in? (check all that apply)(Required)

NAD+ Injectable $140 Cellular energy and healthy aging support

NAD+ Nasal Spray $110 Convenient NAD+ support without injections

Niagen Injectable $300 Cellular energy support from an NAD+ precursor

Sermorelin Injectable $150 Peptide support for longevity focused care

PT 141 Combo From $150 Discreet support in one dissolvable tablet

Tadalafil 20mg From $68 Prescription sexual wellness support

Sildenafil 100mg From $62 Prescription sexual wellness support

Glutathione Injectable $135 Antioxidant support for skin and wellness

GHK Cu Cream From $115 Copper peptide support for skin renewal

GHK Cu Hair Foam $125 Copper peptide support for scalp and hair

Lipo+ Injectable $140 Injectable support for structured weight management plans

MIC Injectable $140 Lipotropic support for weight management routines

B12 Injectable $65 Energy and performance support

PT-141 Combo already includes tadalafil — choose the combo, or select Tadalafil or Sildenafil individually, not all three. GHK-Cu Cream targets skin and face; Hair Foam targets scalp and hair. Selecting a treatment is a request, not a guarantee — your provider will review your health history and approve what’s appropriate for you.

Where do you live?(Required)

We’ll use this to check whether Signal-RX is available in your state.

Sorry, we currently cannot provide services in your selected state. We cannot process your intake at this time.

Who is this visit for?

Tell us who will receive care. Using your legal name .

First name(Required)

Last name(Required)

Date of birth(Required)

MM slash DD slash YYYY

Where should we send updates?

Mobile number(Required)

Email address(Required)

We’ll use this email for the patient’s signal-rx account.

Now, a few questions about your health

Answer as accurately as you can. A licensed provider will review your answers.

Sex(Required)

Reproductive Health

Do any of the following currently apply to you? (check all that apply)(Required)

Currently pregnant

Currently breastfeeding

Trying to become pregnant

None of the above

Weight(Required)

Height (Feet)(Required)

Height (Inches)(Required)

Do you currently have, or have you ever been diagnosed with, any of the following conditions?(Required)

High blood pressure (hypertension)

Hyperlipidemia (high cholesterol)

Metabolic Syndrome

Diabetes (Type 1 or Type 2)

Heart disease

Heart Rhythm issues or EKG abnormalities

Heart Failure

Stroke

Peripheral vascular disease

Fatty liver disease (NAFLD or NASH)

Gallstones or other gallbladder disease

Liver Cirrhosis or End Stage Liver Disease

Kidney disease or reduced kidney function

Hypothyroidism or Thyroid Issues

Obstructive sleep apnea

Asthma or COPD

Bleeding or Clotting Disorder

Syndrome of Inappropriate antidiuretic hormone.

No, I have not been diagnosed with any of these conditions

Tell us about your high blood pressure.

Tell us about your high cholesterol.

Tell us about your metabolic syndrome.

Tell us about your diabetes.

Tell us about your heart disease.

Tell us about your heart rhythm issue.

Tell us about your heart failure.

Tell us about your stroke.

Tell us about your peripheral vascular disease.

Tell us about your fatty liver disease.

Tell us about your gallbladder condition.

Tell us about your liver condition.

Tell us about your kidney disease.

Tell us about your thyroid condition.

Tell us about your sleep apnea.

Tell us about your asthma or COPD.

Tell us about your bleeding or clotting disorder.

Tell us about your SIADH.

Do you take psychiatric medications?(Required)

Yes

Please list them.(Required)

Do you smoke or use tobacco/nicotine/vape products?(Required)

Never

Former — I quit

Current

How much and how often do you smoke or use nicotine?(Required)

When did you quit, and how much did you use?(Required)

What is your most recent blood pressure reading?

Normal (<120/<80)

Elevated (120–129 and <80)

High Blood Pressure (130–139 or 80–89)

High Blood Pressure (≥140 or ≥90)

Do you take any blood-thinning medications (anticoagulants or antiplatelets)?(Required)

Yes

Please list them.(Required)

Do any of your immediate family members have a history of the following? (check all that apply)(Required)

Heart disease

Stroke

High blood pressure

High cholesterol

Diabetes

Blood clots / clotting disorder

Autoimmunity

None of the above.

Have you had any of the following surgeries or procedures? (check all that apply)(Required)

Heart or vascular surgery (bypass, stents, etc.)

Gallbladder removal

Weight-loss / bariatric surgery

Organ transplant

Other major surgery

None

Please describe your surgeries and approximate dates.(Required)

Do you have a primary care provider (regular doctor)?(Required)

Yes

Have you had a general check-up or routine physical in the past 12-18 months?(Required)

Yes

Do you take medications?(Required)

Yes

Please list all medications you currently take.(Required)

Do you have any allergies?(Required)

Yes

Include any allergies to food, dyes, prescription, or over-the-counter medicines (e.g., antibiotics, allergy medications), herbs, vitamins, supplements, or anything else.(Required)

Do you have a personal history of cancer?(Required)

Yes

Please provide details.(Required)

Do any immediate family members have a history of cancer?(Required)

Yes

Which relative(s) and what type of cancer?(Required)

Have you used NAD+ or NR (nicotinamide riboside) products before?(Required)

Never

Yes — injections or IV

Yes — oral/other

How did you tolerate it?(Required)

Do you have a history of low blood pressure, fainting, or frequent dizziness?(Required)

Yes

Please describe.(Required)

Do you have chronic nasal or sinus problems (congestion, polyps, frequent nosebleeds, or prior nasal surgery)?(Required)

Yes

Please describe.(Required)

Are you allergic to sulfa drugs or sulfur-containing compounds?(Required)

Yes

e.g., garlic, onions, glaucoma medication

Please describe.(Required)

Have you ever had wheezing, chest tightness, or trouble breathing after an injection, infusion, or new medication?(Required)

Yes

Please describe.(Required)

Have you used glutathione (injection, IV, or oral) before?(Required)

Yes

Please describe.(Required)

Are you allergic to cobalt or vitamin B12?(Required)

Yes

Have you been diagnosed with Leber's disease (an inherited optic-nerve/eye condition)?(Required)

Yes

Do you take nitrates or nitroglycerin in ANY form?(Required)

Yes

Includes nitroglycerin tablets/patches/sprays, isosorbide, and recreational “poppers” (amyl nitrite).

Do you take an alpha-blocker (e.g., tamsulosin/Flomax, doxazosin) or riociguat (Adempas)?(Required)

Yes

Which medication and dose?(Required)

In the past 6 months, have you had a heart attack, stroke, unstable chest pain, or a serious heart-rhythm problem?(Required)

Yes

Please describe.(Required)

Has a doctor ever told you it's unsafe for you to have sexual activity because of a heart condition?(Required)

Yes

Have you ever had sudden vision loss, sudden hearing loss, or been diagnosed with retinitis pigmentosa?(Required)

Yes

Have you ever had an erection lasting more than 4 hours (priapism), or a penile condition such as Peyronie's disease/significant curvature?(Required)

Yes

Do you have sickle cell disease, leukemia, or multiple myeloma?(Required)

Yes

Do you have a history of melanoma, or any dark/changing moles?(Required)

Yes

Are you allergic or sensitive to copper (e.g., reactions to copper jewelry or a copper IUD)?(Required)

Yes

Have you been diagnosed with Wilson's disease (a copper-metabolism disorder)?(Required)

Yes

Do you have an active skin infection, open wounds, or a severe skin condition (eczema/psoriasis) in the area where you'd apply it?(Required)

Yes

Have you been diagnosed with hereditary hemochromatosis?(Required)

Yes

Do you use any prescription or over the counter topicals (e.g., retinoids/tretinoin, steroid creams)?(Required)

Yes

Please list them.(Required)

Have you been diagnosed with diabetic retinopathy (diabetes-related eye disease)?(Required)

Yes

Anything else you’d like the provider to know?(Required)

Yes

Optional. Share anything that may help with your review.

What would you like the provider to know?(Required)

Almost done—what’s the home address?

Use the current home address for the person receiving care. Billing can be different at checkout.

Street address(Required)

Apartment or unit (optional)

City(Required)

ZIP code(Required)

Informed Consent for Telehealth & Treatment

Please review the following terms regarding your asynchronous visit and treatment plan. Click the headings to expand each section.

Nature of Telehealth & Technology Risks

I understand that consultations or follow-up care conducted online are technical in nature and that problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the practitioner and the practitioner makes no guarantee that such services will be available or work as expected.

Privacy, Security & Location

I agree to take full responsibility for the security/privacy of any communications or treatment on my own computer and in my own physical location. I understand I am solely responsible for maintaining the strict confidentiality of my user ID and password and not allowing another person to use my user ID to access the services. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.

Confidentiality & No Recording

I understand that there will be NO recording of any of the online sessions and that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without my written permission, except where disclosure is required by law.

Off-Label Use & Treatment Risks

I understand that the use of products such as NAD+, Glutathione, and Peptides for anti-aging or wellness purposes may be considered “off-label.” While legally prescribed, they may not be FDA-approved specifically for these purposes. Potential benefits include improved cellular health and recovery, but side effects may occur. I agree to report to my primary care doctor or to the emergency room if an adverse side effect occurs.

Cancellation Policy

Fees for 24-hour Cancellation Policy and Missed Visits apply to Telehealth visits in accordance with SignalRx policies. If something occurs to prevent or disrupt any scheduled appointment due to technical complications, I agree to text/call my provider back.

Identity Verification

I understand that, after I accept Signal-RX’s Terms and Privacy Policy and pay for an eligible telehealth consultation, Signal-RX may automatically begin an identity-verification check through Vouched Identity, Inc. Signal-RX may provide Vouched with the patient’s name, date of birth, email address, telephone number, home address, and the Internet Protocol address associated with the consultation checkout for identity-verification and fraud-prevention purposes. Identity verification does not make a clinical or prescribing decision. If a government-issued identification document, facial image, or facial or biometric processing is required, the Verification page will provide the applicable Vouched notices and require a separate fresh affirmative action before that step begins. I can review Signal-RX’s Terms and Privacy Policy, the Vouched End User Privacy Statement, the Vouched End User Terms, and the Vouched Biometric Privacy Notice.

Patient Acknowledgement & Signature

By typing my signature or checking the box below, I agree to use this digital action as a substitute for my handwritten signature, and I agree to all of the terms and conditions above. I certify that I have read and fully understand the information provided.

Consent(Required)

I have read the above information, I understand the risks and would like to proceed.