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 | 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 5Telemedicine 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 6Telemedicine 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 7Telemedicine Survey | COVID-19

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

Step 8Telemedicine Survey | Pharmacy Request

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

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 | 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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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.Have you been in close contact with a laboratory confirmed COVID-19 case? *
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Q3.Have you been in contact with a person hospitalized with acute lower respiratory illness of unknown origin? *
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Q4.Do you have any history of travel to or from an affected geographic area with widespread community transmission? *
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Q5.Do you have a history of international travel or a cruise? *
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Q6.Are you 65 and or older with a history of chronic health conditions? *
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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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