Patient Intake Form

Complete your secure medical assessment to get started. Our NP reviews every intake personally within 48 hours.

Personal
Info

Medical
History

Acknowledge-
ments

$99
Payment

Choose
Plan

📋 Step 1 of 5

Personal Information

Basic details to create your secure patient profile.

Your Details

First Name *

Please enter your first name.

Last Name *

Please enter your last name.

Email Address *

Please enter a valid email address.

Phone Number *

Please enter your phone number.

Date of Birth *

Please enter your date of birth.

Biological Sex *

State of Residence *

Please select your state.

Height & Weight

Feet *

Inches *

Weight (lbs) *

Calculating...

Based on your height and weight

Goal Weight (lbs)

Additional

How did you hear about us?

🔒 Your information is encrypted and HIPAA-compliant

✅ Step 3 of 5

Acknowledgements & Consent

Please read and check all boxes below. All items are required to proceed.

📋

Required Acknowledgements

Check all 6 boxes to continue to payment

I understand that submission of this form does not guarantee a prescription. I understand a licensed provider will review my information to determine if treatment is clinically appropriate. I understand this is a monthly subscription program that will auto-renew unless canceled before the next billing date. I understand this service does not replace my primary care provider and is not intended for emergency medical situations. I consent to telehealth services and authorize Optimal Direct to contact me via email and phone regarding my care. I confirm all information provided is accurate and complete to the best of my knowledge.

0 of 6 checked

🔒 Your consent is recorded securely with your intake file

💳 Step 4 of 5

$99 Assessment Fee

One-time fee to begin your NP intake review. Credited toward your first month upon approval.

^$99

One-time NP Intake Assessment Fee

What's included with your $99

Personal review of your full medical intake by our licensed NP
Medication eligibility determination
Custom treatment protocol recommendation
Response within 48 business hours
$99 credited toward your first subscription month

Card Details

VISA

AMEX

DISC

Cardholder Full Name *

Please enter the cardholder name.

Card Number *

Please enter a valid 16-digit card number.

Expiration Date *

Please enter a valid expiry date.

CVV / CVC *

Please enter your CVV.

Billing ZIP Code *

Please enter your billing ZIP code.

🔒 256-bit SSL encrypted · PCI compliant · Never stored on our servers

🎯 Step 5 of 5

Reserve Your Monthly Plan

Select the plan that best fits your goals. Your plan activates only after NP approval — your $99 will be credited.

$149_/mo

Medications Only

Script + refills, async support

NP-prescribed medication
Monthly refill management
Async messaging

$199_/mo

Essentials

Oral meds + monthly NP visit

Monthly NP video visit
Oral medication
Meal guidance
Patient portal access

$299_/mo

Premium

GLP-1 injectable + bi-weekly visits

Bi-weekly NP video visits
GLP-1 injectable medication
Custom nutrition plan
Priority messaging
Dosage adjustments

$449_/mo

VIP Concierge

Weekly visits + dual medication

Weekly NP video visits
Dual medication protocol
Personal health coaching
Same-day messaging
Full monthly lab panel

📅 You will NOT be charged for your plan today.
Your $99 has been processed. Your monthly plan activates only after NP approval. You'll receive a secure link by email to confirm and activate your plan.

🔒 No charge for your plan until NP approval

🎉

You're All Set!

Ref # OD-000000

Your intake has been submitted and your $99 assessment fee has been processed. Our Nurse Practitioner will personally review your case within 48 business hours.

📋 What happens next:

NP reviews your complete medical intake (within 48 hrs)
You receive an approval email with your treatment plan
Click the secure link to activate your chosen monthly plan
Your medication ships discreetly to your door (2–3 days)
Schedule your first NP video visit via the patient portal

📧 A confirmation email has been sent to your email address.
Add care@optimaldirect.com to your safe senders to ensure you receive your approval email.

Ready to Begin?

Patient Intake Form

Personal Information

Medical History

Acknowledgements & Consent

Required Acknowledgements

$99 Assessment Fee

What's included with your $99

Reserve Your Monthly Plan

You're All Set!

📋 What happens next:

Name of your Primary Care Provider (MD, NP, PA) (include the practice name if known)

Please answer the following:

Height & Weight

Services

Company

Legal

Ready to Begin?

Important Notice

Patient Intake Form

Personal Information

Medical History

Acknowledgements & Consent

Required Acknowledgements

$99 Assessment Fee

What's included with your $99

Reserve Your Monthly Plan

You're All Set!

📋 What happens next:

Name of your Primary Care Provider (MD, NP, PA) (include the practice name if known)

Please answer the following:

Height & Weight

Services

Company

Legal