Start Your Visit

Complete your health intake.

Fill out the form below so an independent licensed clinician can review your information and determine whether treatment is appropriate. This process is confidential.

HIPAA-aligned practices

Secure & confidential

Clinician-reviewed

Personal Information

Your personal details are kept confidential and shared only with the reviewing clinician.

Full Name *

Date of Birth *

Email Address *

Phone Number *

State of Residence *

Medical History

This information helps the clinician evaluate your eligibility. Be thorough and honest.

Current Medications

Medical Conditions & Allergies

Treatment Interest

Select your preferred plan and describe your concerns. The clinician will make the final determination.

Preferred Plan *

Mint Core — $69/month (Tadalafil 10mg, 4 troches)Mint Enhanced — $119/month (Tadalafil 10mg + Paroxetine 10mg, 8 troches)Mint Elite — $159/month (Tadalafil 10mg + Paroxetine 10mg + Oxytocin 100IU, 8 troches)

Describe Your Symptoms or Concerns *

Consent & Agreements

Please review and agree to the following before submitting your intake.

I have read and agree to the Terms of Use. *

I have read and agree to the Privacy Policy. *

I have read and agree to the Telehealth Consent and understand that telehealth services are provided by independent licensed clinicians. *

By submitting, you confirm that the information provided is accurate to the best of your knowledge. Submitting this form does not guarantee a prescription.

ENDUREMINT LLC provides website, marketing, administrative, and customer support services. Telehealth services are provided by independent licensed clinicians, and prescription fulfillment is handled by licensed pharmacies. EndureMint does not provide medical advice or pharmacy services. Compounded medications are not FDA-approved.