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- Step 1 of 2

Select Your Gift *

• Free Dark Spot Cream
• Free ED Medication Sample
• Free Multivitamins for Kids
• Free Private Area Dark Spot Cream
• Free BODY Dark Spot Cream
• Free HRT Consultation ($150)
• Free Symptom Checker (40+ Health)
• Free GLP-1 Pill Sample ***

Full Name *

Phone Number *

Email Address *

Date of Birth *

Next

Do you currently have IEHP insurance? *

• Yes
• No
• Not sure

How many prescriptions do you take each month? *

• 0-1
• 2-4
• 5 or more
• More than 10

Requirement for GLP-1 pill sample: must have at least 5 monthly prescriptions.

Are you interested in transferring your prescriptions to Doctor's Choice Pharmacy? *

• Yes
• Maybe
• No

Comments or Questions

Acknowledgment *

• I understand that prescription is required.
• I understand that eligibility depends on insurance, prescription history, clinical appropriateness, and availability.
• I understand that submitting this form does not guarantee medication, sample, or approval.
• I authorize Doctor’s Choice Pharmacy to contact me about this request.

HIPAA & Consent Acknowledgment *

• I consent that this form will be reviewed by Doctor’s Choice Pharmacy and/or a licensed healthcare provider.
• I understand that my information is protected under HIPAA and will remain confidential.
• I authorize Doctor’s Choice Pharmacy to contact me regarding this request.
• I confirm that I am physically located in California and eligible for this service.

Submit My Gift Request

Important Notice

All free gifts, samples, compounded medications, consultations, and promotional offers are subject to patient eligibility, professional review, and applicable California laws and regulations.

Certain products may require a valid prescription from a licensed healthcare provider before they can be dispensed. If you do not currently have a prescription, Doctor’s Choice Pharmacy may help connect you with an independent licensed provider for evaluation, when appropriate.

Submission of this form does not guarantee approval, prescription issuance, insurance coverage, or dispensing of any medication or product. Offers available to eligible California patients only.