New Patient Intake - Dynamic Rx Labs

Welcome to Dynamic Rx Labs!

New Patient Intake Form
Thank you for choosing Dynamic Rx Labs!

We are a closed-door compounding pharmacy, which means we do not have a retail storefront for patient pickups. All prescriptions are shipped directly to our patients.

To help us process your prescription as quickly as possible, please complete the form below.

What happens next?
1. Complete and submit this intake form. The sooner you complete this form, the faster we can begin processing your order.
2. You'll receive a separate secure link to pay for your prescription. (Please be aware that your card information will not be saved. You will need to enter your card information again for your next transaction.)
3. Once payment is received, your prescription will be reviewed, fulfilled, and prepared for shipment.Orders are typically fulfilled within 2 business days after successful payment and will ship on the next available shipping day.
4. If we need any additional information, one of our team members will contact you.

For subsequent refills, please visit https://dynamicrxlabs.com/refill/ and submit your refill request. We do not automatically refill medications. Please note that your medication is temperature-sensitive and should be refrigerated promptly upon receipt.

Name

Date of Birth

Address

Additional Delivery Instructions

Phone Number

Driver's License/ID Number (if prescribed testosterone or another controlled substance)

Medication Name

Dose (if known)

Have you taken this medication before?

Yes No

What dose did you take? When was your last injection?

Allergies

No Known Drug Allergies Yes, please list

Medication Allergies

Would you like to speak with one of our pharmacists about your medication before it is shipped?

Yes, please have a pharmacist contact me. No, I do not need a consultation at this time.

Our pharmacists are available for consultations Monday–Friday from 9 AM–4 PM. Please share the preferred 2-hour time frame during which you would like to receive a call from us.

Patient Acknowledgment

By submitting this form, I certify that I have carefully reviewed and verified all of the information provided above, including my name, date of birth, shipping address, phone number, email address, allergies, and prescription details. I understand that this information will be used to process and ship my prescription.

I acknowledge that Dynamic Rx Labs is not responsible for delays, misdeliveries, or other issues resulting from incorrect or incomplete information submitted on this intake form, including but not limited to an incorrect shipping address, phone number, email address, or prescription information. Any additional shipping or processing costs incurred due to incorrect information may be the responsibility of the patient.

By submitting this form, I authorize Dynamic Rx Labs to process my prescription.

I have reviewed all information above and confirm that it is complete and accurate.

Yes

Date

Monday – Friday: 8AM PST – 5PM PST
Saturday – Sunday: Closed

info@dynamicrxlabs.com
Phone: (425) 255-9000

Compounded drugs are not FDA-approved. Compounded drugs may be appropriate if an FDA-approved drug is not commercially available or cannot meet a patient's medical needs. Compounding pharmacies are regulated by State Boards of Pharmacy and must follow regulations set by the United States Pharmacopeia to ensure strict quality and safety standards.

*Compounded GLP-1s: This is a compounded drug that has not been approved by the FDA, has not been reviewed for safety, effectiveness, or quality, and has not been demonstrated to the FDA to be safe or effective for its intended use. The processes by which this drug is manufactured have not been reviewed by the FDA. FDA-approved alternatives are available.