Request Care in 4 Easy Steps

Pre-Authorize Payment of Virtual Consult Fees

Please complete the form below to request care from a licensed medical provider in Arizona. This information is used by the medical provider to review your request and provide a care recommendation.

1. Choose Pharmacy

Enter your Zip Code or city to find a pharmacy.

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Your Selected Pharmacy
You can change your selected pharmacy later.

2. Patient Information

3. Patient Health Information

Controlled substances cannot be prescribed through Push Health.

4. Confirm Request and Agree to Terms

After you submit your request, a licensed medical provider in your area will review your information. You will be notified by email when that provider has reviewed your request and, if appropriate, made care recommendations.

By checking this box, you indicate that you, as the patient or legal guardian of the patient, agree to the Terms of Service, Privacy Policy and Consent to Telehealth.