Demo Intake — Thyroid Refills | Evolve Health (Preview)

Step 1 of 13 — Eligibility gates

Eligibility gates

Are you having any urgent symptom listed above right now? *

No Yes

I confirm each of the following (all must apply): *

I am 18 years of age or older. I am physically located in Texas during this evaluation. I understand this is not emergency care. I understand a Clinician will review my answers and treatment is not guaranteed.

Your date of birth *

Step 2 of 13 — About you

About you

Legal first and last name *

Street address *

City *

State *

ZIP code *

Mobile phone *

Email *

How may we contact you about this care?

Phone call Text message Secure portal message

May we leave a generic voicemail (no medical details)? *

Yes No

Step 3 of 13 — Identity verification

Identity verification

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart.

Photo of the FRONT of your government ID *

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Take a photo

Demo only — files are never uploaded.

Upload a photo

Photo of the BACK of your ID — the barcode side *

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Take a photo

Upload a photo

Selfie *

Look at the camera like a passport photo — no sunglasses or hat.

Take a photo

Upload a photo

Identity confirmation *

The name and date of birth on my ID match the information on this form.

Step 4 of 13 — Continuation-only gate

Continuation-only gate

This service continues thyroid medicine that a clinician has already prescribed for you at a dose that is working well. It is a great fit when your dose has been stable, your recent labs are on track, and you feel well. New diagnoses, first-time starts, and dose changes begin with a live visit so the Clinician can evaluate you fully and arrange the right labs.

Which statement fits you best? *

I already take thyroid medicine prescribed for me, at a stable dose, and I need a refill of the same medicine and dose I have never taken thyroid medicine, or I want to start it I want to change my dose, change my medicine, or I think my dose is not right I have symptoms of a thyroid problem but no diagnosis

Who originally diagnosed your thyroid condition, and approximately when? (clinic or clinician type, city, and year) *

What is your diagnosed thyroid condition, as you were told? *

Underactive thyroid (hypothyroidism) Thyroid removed by surgery — replacement medicine After radioactive iodine treatment — replacement medicine Overactive thyroid (hyperthyroidism) on maintenance medicine Other Unsure

If other or unsure, describe

How long have you been on your current medicine and dose without any change? *

Less than 6 weeks 6 weeks to 3 months More than 3 months More than 1 year

May we request records and prescription history from your previous clinician or pharmacy, if needed to verify your treatment? *

Yes No

Step 5 of 13 — Current medication and dose verification

Current medication and dose verification

Please have your current prescription bottle in front of you and copy the label exactly. The Clinician compares your answers with the bottle photo and your prescription history — the refill, if approved, matches the verified medicine and dose exactly.

Thyroid medicine name, exactly as printed on the bottle *

Strength / dose, exactly as printed on the bottle (for example, the number and unit) *

How do you take it? (number of tablets, time of day, with or without food) *

How many days per week do you take it? *

Every day (7 days) A different schedule — I will describe it

If a different schedule, describe it exactly as prescribed

Pharmacy where this was last filled, and the date of the last fill *

Upload a clear photo of your current prescription bottle label (name, medicine, dose, and directions readable) *

Demo only — files are never uploaded

How many days of medicine do you have left? *

In the past month, how often did you miss a dose? *

Never Rarely (1–2 times) Sometimes (about once a week) Often (more than once a week)

Do you take your thyroid medicine at least 30–60 minutes before eating, or 3–4 hours after eating, and separated from iron, calcium, or antacids? *

Yes, consistently No Unsure — I would like guidance

Steady timing helps your dose work the way the Clinician intends. If timing has been hard to keep, the Clinician may review it with you on a video visit before refilling.

Step 6 of 13 — Labs: TSH capture

Labs: TSH capture

A recent TSH result is required for a thyroid refill — it confirms your current dose is right for you. If your most recent TSH is outside the required window, the Clinician will arrange updated labs and a video or in-person visit before any refill, so your care stays on track.

Date of your most recent TSH blood test *

What was the TSH result, if you know it? (number and unit as reported)

Where was the test done? (lab or clinic name and city) *

Upload your lab report if you have it (PDF or clear photo)

Demo only — files are never uploaded

Were any other thyroid labs done at the same time (for example free T4)? If yes, give dates and results if known.

Step 7 of 13 — Symptom screen: over- and under-replacement

Symptom screen: over- and under-replacement

Feeling well on a steady dose is part of what makes a refill safe. New or worsening symptoms can mean a dose needs review — that review happens on a live visit with labs, and this screen helps the Clinician get you there promptly. If your answers show new or worsening symptoms in either direction, the Clinician will convert your case to a video visit and may arrange labs before any refill decision, so the dose is reviewed with you live.

In the past 4–6 weeks, have you had any of these possible signs of TOO LITTLE thyroid hormone (under-replacement)?

In the past 4–6 weeks, have you had any of these possible signs of TOO MUCH thyroid hormone (over-replacement)?

Overall, how do you feel on your current dose compared with when it was last reviewed? *

I feel well — about the same Somewhat worse Much worse

Current weight *

Has your weight changed by more than about 10 pounds in the past 6 months without trying? *

No Yes

If yes, describe — include dates (amount, direction, timing)

Step 8 of 13 — Red-flag exits

Red-flag exits

The items below need prompt live evaluation, not an online refill. Checking any one of them stops this form and shows you the safest next step — your care team will still help you get to the right place.

Check YES for any that apply to you now:

Chest pain, trouble breathing, or fainting A racing, pounding, or irregular heartbeat that is new, severe, or comes with chest pain or lightheadedness Confusion, extreme sleepiness, or trouble staying awake Swelling of the face, lips, or tongue, or trouble swallowing A rapidly growing neck swelling, new hoarseness, or trouble breathing when lying flat Fever with severe muscle weakness, vomiting, or feeling very unwell I am pregnant now, or I think I might be pregnant None of the above

Are you currently thinking about harming yourself or someone else? *

No Yes

Step 9 of 13 — Dose-change requests

Dose-change requests

Dose changes are never made through this refill form — they begin with a live visit and current labs, which keeps every change careful and well documented.

Are you asking for any change to your thyroid medicine or dose with this request? *

No — refill the same medicine at the same dose Yes — I want a change

Is there anything about how your medicine is working that you would like the Clinician to know?

Step 10 of 13 — Health history

Health history

If yes, describe — include dates

Any surgery or hospital visit since your thyroid dose was last reviewed? *

No Yes

If yes, describe — include dates

Who is your primary care clinician, and when was your last visit?

Who manages your thyroid care currently, if different from above?

Step 11 of 13 — Medicines and allergies

Medicines and allergies

List every prescription medicine, over-the-counter medicine, vitamin, supplement (including iron, calcium, biotin, and soy products), and recreational substance you currently use. Include dose and how often you take it. Be sure to include heart, blood-pressure, cholesterol, diabetes, mood, seizure, and weight-management medicines, and anything started or stopped since your last TSH. *

Some medicines and supplements change how thyroid medicine is absorbed or how labs read. The Clinician reconciles this full list against your bottle photo and TSH before any refill decision.

Medication allergies or serious reactions (write "None" if none) *

Have you had an allergic reaction or serious side effect to any thyroid medicine or its inactive ingredients (for example, a dye or filler)? *

No Yes Unsure

If yes or unsure, describe

Step 12 of 13 — How you will receive medication

How you will receive medication

If the Clinician approves a refill, your prescription will be sent to your own pharmacy for pickup. Pickup is recommended for a first prescription with us: the pharmacy confirms your identity at the counter, which keeps the first fill safest. If your identity could not be fully verified online, your prescription will be pickup-only.

Pharmacy pickup: *

Pharmacy pickup — prescription sent to the pharmacy I name belowMail delivery — Evolve mail plan: one flat total (visit + medication + shipping); mailed in plain packaging, adult signature required.

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Pharmacy name and city (for pickup) *

Insurance can pay for medication only at your own pharmacy with pickup.

Step 13 of 13 — What happens next + consent

What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; compare your bottle photo and prescription history with your answers; request records or updated labs, including a new TSH; schedule a video or in-person evaluation — including for any start, dose change, symptom change, pregnancy, or lab that is outside the required window; or recommend primary care, specialist, urgent, or emergency evaluation. No refill or medicine is promised, and this form does not create a new diagnosis. Payment: your exact price is shown before checkout. Your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.

Full legal name (acts as your signature) *

Emergency — please read first

Eligibility gates

About you

Identity verification

Continuation-only gate

Current medication and dose verification

Labs: TSH capture

Symptom screen: over- and under-replacement

Red-flag exits

Dose-change requests

Health history

Medicines and allergies

How you will receive medication

What happens next + consent

Please pause — next step for your safety

Demo complete