Doctor Appointment

First Name

Middle Name

Last Name

Gender *

Male

Female

DOB

Phone Number *

Best Time to call you *

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. *

Yes I acknowledge

What is your chief complaint? * What is your Height: * What is your weight: *

Example: 190 (numerical only in pounds)

What current medications are you taking? *

Are you Diabetic? *

Yes

Not Applicable

Do you take oral or insulin to treat diabetes? *

Oral

Insulin

Both

Not Applicable

Do you have any allergies: * Are you allergic to any medication? *

Have you seen doctor in last 12 months: *

Yes

Have you recently experienced a cough or allergy symptoms? Such as runny nose, itchy eyes, or scratchy throat? *

Yes

Do you experience Seasonal Allergies? *

Yes

Do you often feel sluggish, lack energy, or get frequent colds or flu? *

Yes

Do you have chronic heartburn or acid reflux? *

Yes

How long have you exhibited symptoms of seasonal allergies? *

If no seasonal allergies, put NONE

What symptoms do you experience? *

(ex itchy watery eyes, cough, runny nose)

Are you currently taking an anti-histamine? *

Yes

Would you be interested in a anti-histamine if the physician deems you a good candidate for this treatment option? *

Yes

Are you running a fever of 100F or greater? *

Yes

Flu Screening

Are you experiencing any of these symptoms? *

None

Sore Throat

Cough

Nasal Congestion

Runny Nose

Extreme Tiredness

Body Aches

Muscle Aches

Vomiting

Diarrhea

Have you been experiencing these symptoms for longer than 4 days? *

Yes

Not Applicable

Flu Screening

Are you having trouble breathing or shortness of breath? *

Yes

Flu Screening

Are you currently taking any medications to self-treat your symptoms? *

Yes

Flu Screening

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? *

Yes

Have you been in close contact with a laboratory confirmed COVID-19 case? *

Yes

Have you been in contact with a person hospitalized with acute lower respiratory illness of unknown origin? *

Yes

Do you have any history of travel to or from an affected geographic area with widespread community transmission? *

Yes

Do you have a history of international travel or a cruise? *

Yes

Are you 65 and or older with a history of chronic health conditions? *

Yes

If available, would you like your prescription delivered directly to your home? *

Yes

Step 1Personal Details

Step 2Personal Details

Step 3Telemedicine Survey | Telemed Acknowledgement

Step 4Telemedicine Survey | General

Step 5Telemedicine Survey | Seasonal Allergies

Step 6Telemedicine Survey | Flu Screening

Step 7Telemedicine Survey | COVID-19

Step 8Telemedicine Survey | Pharmacy Request