Step 1Personal Details

Please fill out your personal details to speak with an MD. All personal details are stored in a secure HIPAA compliant manner.

Step 2Personal Details

Please fill out your personal details to speak with an MD. All personal details are stored in a secure HIPAA compliant manner.

Step 4Telemedicine Survey | Telemed Acknowledgement

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Acknowledgement

Step 5Telemedicine Survey | General

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Example: 190 (numerical only in pounds)

Step 6Telemedicine Survey | Seasonal Allergies

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

If no seasonal allergies, put NONE

(ex itchy watery eyes, cough, runny nose)

Step 7Telemedicine Survey | Flu Screening

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Flu Screening

(check all that apply)

Flu Screening

Flu Screening

Flu Screening

Step 8Telemedicine Survey | COVID-19

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 9Telemedicine Survey | Pharmacy Request

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 10Telemedicine Survey | Concierge Telemedicine

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 11Telemedicine Survey | Refill

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Refill

Final Step Please Review before Submission


Personal Information
What is your Language ? *
First Name *
Middle Name
Last Name *
Gender
Street Address *
City *
State *
ZIP *
Date of Birth *
Phone Number *
Best Time to call you *
Email

Telemedicine Survey | Telemed Acknowledgement
Q1.By checking this box and requesting an appointment, you will be provided the opportunity to consult with a physician that is licensed in your state of residence. This does not guarantee that the requested medications will be prescribed. We rely on the experience and medical knowledge of our highly qualified physicians to provide the best patient care possible through telemedicine. *
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Q2.By checking this box you are agreeing to our terms and conditions and our refund policy. Refunds are made at our discretion and are not guaranteed. *
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Q3.By checking this box you are agreeing that we are independent of any pharmacy, and any guarantees made regarding medication delivery are not reflected by us. Medications are not included in the appointment fee. *
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Q4.The patient expressly acknowledges and consents that patient consults may be conducted by a licensed nurse practitioner or licensed physician. *
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Telemedicine Survey | General
Q1.What is your chief complaint? *
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Q2.What is your Height: *
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Q3.What is your weight: *
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Q4.What current medications are you taking? *
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Q5.Are you Diabetic? *
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Q6.Do you take oral or insulin to treat diabetes? *
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Q7.Do you have any allergies: *
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Q8.Are you allergic to any medication? *
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Q9.Have you seen doctor in last 12 months: *
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Q10.Have you recently experienced a cough or allergy symptoms? Such as runny nose, itchy eyes, or scratchy throat? *
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Q11.Do you experience Seasonal Allergies? *
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Q12.Do you often feel sluggish, lack energy, or get frequent colds or flu? *
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Q13.Do you have chronic heartburn or acid reflux? *
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Q14.Are you currently experiencing any of the following: *
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Q15.Do you experience any of the following skin issues: *
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Q16.Do you experience any of the following conditions: *
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Q17.History of retina disease? *
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Q18.History of arrhythmia or heart disease? *
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Q19.History of seizures? *
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Q20.History of low blood counts? *
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Q21.History of asthma or copd? *
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Q22.Pregnancy status? *
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Telemedicine Survey | Seasonal Allergies
Q1.How long have you exhibited symptoms of seasonal allergies? *
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Q2.What symptoms do you experience? *
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Q3.Are you currently taking an anti-histamine? *
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Q4.Would you be interested in a anti-histamine if the physician deems you a good candidate for this treatment option? *
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Telemedicine Survey | Flu Screening
Q1.Are you running a fever of 100F or greater? *
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Q2.Are you experiencing any of these symptoms? *
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Q3.Have you been experiencing these symptoms for longer than 4 days? *
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Q4.Are you having trouble breathing or shortness of breath? *
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Q5.Are you currently taking any medications to self-treat your symptoms? *
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Telemedicine Survey | COVID-19
Q1.Are you experiencing any of the following symptoms: fever, cough, shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell? *
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Q2.Are you COVID positive currently or exhibiting symptoms that are concerning for COVID? *
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Q3.Do you have any chest pain? *
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Q4.Do you have any shortness of breath? *
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Q5.Have you been in close contact with a laboratory confirmed COVID-19 case? *
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Q6.Are you exhibiting symptoms that are concerning for COVID? *
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Q7.Have you been in contact with a person hospitalized with acute lower respiratory illness of unknown origin? *
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Q8.Do you have any history of travel to or from an affected geographic area with widespread community transmission? *
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Q9.Do you have a history of international travel or a cruise? *
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Q10.Are you 65 and or older with a history of chronic health conditions? *
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Q11.Are you wanting to receive a recommended prophylaxis kit of medications in case you become sick from being exposed to COVID-19? *
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Q12.Are you willing to waive the step of having to wait on a phone call from the physician to receive the prescription for the COVID-19 prophylaxis kit of medications? *
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Q13.Patient agrees that unless otherwise requested by the treating physician, doctor-patient consults shall be conducted via Asynchronous communication, and patient expressly waives the right to have doctor-patient consults conducted by way of other telehealth modalities, including but not limited to direct video communication (Synchronous), Remote Patient Monitoring, Mobile Health (mHealth), or other audio/video direct person to person collaboration. *
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Telemedicine Survey | Pharmacy Request
Q1.If available, would you like your prescription delivered directly to your home? *
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Q2.Pharmacy Lookup *
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Telemedicine Survey | Concierge Telemedicine
Q1.Interested in Concierge Telemedicine? *
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Q2.Can we contact you regarding this request to get you more information? *
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Telemedicine Survey | Refill
Q1.Is this request for a prescription refill? *
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