Prescription Refill Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 66Email *NextFirst Name *Last Name *PhonePreviousNextDate of Birth *Confirm Date of Birth *Check to confirm date of birthGender *MaleMaleFemaleWeight *Height *4' 0''4' 0''4' 1''4' 2''4' 3''4' 4''4' 5''4' 6''4' 7''4' 8''4' 9''4' 10''4' 11''5' 0''5' 1''5' 2''5' 3''5' 4''5' 5''5' 6''5' 7''5' 8''5' 9''5' 10''5' 11''6' 0''6' 1''6' 2''6' 3''6' 4''6' 5''6' 6''6' 7''6' 8''6' 9''6' 10''6' 11''7' 0''7' 1''7' 2''7' 3''7' 4''7' 5''7' 6''7' 7''7' 8''7' 9''7' 10''7' 11''RaceSelectAlaska NativeAmerican IndianAsianBlack/African AmericanHawaiian or Other Pacific IslanderHispanicWhiteOtherOther Race *Marital StatusSelectSingleMarriedDivorcedSeparatedPreviousNextWho is the patient? *Myself (the patient)Myself (the patient)Pediatric (2-17 yrs old)FriendPreviousNextWhat disease are you suffering from? *PreviousNextSelect Your Location *TexasTexasKansasGeorgiaFloridaNevadaMississippiLouisianaAlaskaSouth CarolinaSouth DakotaAlabamaArkansasNew MexicoLet's match you with an authorized medical professional in your state.PreviousNextConsent to use information *We kindly request your consent to use the information collected during your interactions with our platform, to ensure transparency and data protection. Visit our privacy policy for more informationPreviousNextAuthorization to administer treatment and informed consent *I thus give my consent for the medical staff at ReddyDoc to examine my medical background and provide telemedicine (synchronous or asynchronous) healthcare to me, the patient.In the event that my chosen or preferred prescription is possibly hazardous, unsafe, controlled, risky, interacts with another medication I'm taking, or has an adverse drug reaction, I thus give ReddyDoc permission to prescribe an alternate drug.According to what I've been told, telemedicine services are only appropriate for mild to moderately complex medical requirements. I am aware that ReddyDoc will refuse to treat patients with serious or complex diseases and will cancel their appointments.I am aware that, in the absence of a physical examination, ReddyDoc will deliver online medical services based on the medical history I submit. I thus accept full responsibility for any injury or losses that may result from providing false, misleading, or incomplete information.I am aware that using telemedicine has a risk of misdiagnosis because there is no physical exam or in-person evaluation.I consent to phone 911 or follow up with a doctor for an in-person assessment if my symptoms get worse or don't get better quickly.PreviousNextTerms of use *I am aware that if my medical practitioner needs more information or if I submit insufficient medical history, the process could be delayed.I am aware that the consultation charge does not cover the cost of the medicine if I decide to pick up my drug(s) from a pharmacy; I will still be responsible for paying that pharmacy.I've been told that I can use my insurance to pay for my medication at the drugstore.I understand that I must email ReddyDoc to request an alternate medication or out-of-pocket (self-pay) options if my insurer is unable to pay for the required test or medication, or if the cost of the medication is prohibitive. I've been told that insurance restrictions or prescription costs are not acceptable justifications for issuing a refund. The patient is financially accountable for their prescriptions and medical services.PreviousNextDo you have a life-threatening symptom or a medical emergency? *YesNo life-threatening symptomsWe do not, unfortunately, treat life-threatening disorders. Please call 911PreviousNextAre you focused and alert? *YesNoYou must be focused and aware.PreviousNextAre you allergic to any medications? *No, there are no medication allergies (NKDA).YesWhat drugs do you have an allergy to? *PreviousNextWhat underlying medical conditions do you have? *I have no chronic medical or psychiatric issuesHeart diseaseHypertensionLiver diseaseKidney diseaseDiabetesHigh cholesterolThyroid disorderPsychiatric conditionHIV/AIDSOther ConditionList any further health issues you may have. *PreviousNextHeart condition type *Coronary Artery Disease (CAD) or heart attackHeart Valve DiseaseArrhythmias or abnormal heartbeatHeart Failure or CHFCongenital Heart DiseaseCardiomyopathy (Heart Muscle Disease)Pericardial DiseaseOtherList other heart conditions that you have *PreviousNextWhat does your blood pressure usually look like? *Normal (Less than 140/90)Elevated (Less than 160/100)Uncontrolled (Over 160/100)PreviousNextWhat kind of liver diseasePreviousNextType of kidney disease *Kidney stonePolycystic Kidney DiseaseKidney infection or cystNephritis or nephropathyKidney cancerElevated creatinine or low GFRSolitary or Single-functioning KidneyOtherList other kidney disease *PreviousNextHow stable or controlled is your diabetes? *Well controlled (Glucose below 150 or Hba1c less than 8)Somewhat controlled (Glucose below 200 or Hba1c less than 9)Uncontrolled Diabetes (Glucose over 200 or Hba1c over 9)PreviousNextLast thyroid test *Normal TSH level in the last 12 monthsElevated TSH (or low T4 or T3) levelLow TSH (or low T4 OR T3) levelNo thyroid lab test in the last 12 monthsI have symptoms of abnormal thyroid disorderPreviousNextSelect applicable psychiatric condition *DepressionAnxietyPanic disorderBipolar or mood disorderSchizophrenia or psychosisPTSDEating disorderOCDOtherOther condition PreviousNextAre you currently taking any medication? *NoYesEnter medication name *PreviousNextMedication Disclosure Clause *I hereby certify that I am NOT currently taking any medication including OTC or supplements, and agree to indemnify and hold ReddyDoc and its employees harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication or any other vital medical informationPreviousNextSelect Relevant Social History Non-smokerDrink Coffee multiple times a dayCurrent smoker (Vape, cigarette or tobacco)Former cigarette or tobacco usePrescription drug addictionAlcohol addictionPreviousNextWhen was your last in-person visit to the doctor? *Within the past three (3) monthsWithin the last three (3) to six (6) monthsWithin the last six (6) to twelve (12) monthsPreviousNextThe purpose of this visit? *Refill medication(s) that I'm currently takingResume medication(s) I was previously takingStart a new medication that I have NEVER taken beforeSTOP! Use this form to get a medication refill. Go back to our website and choose a disease you want to treat.PreviousNextWhich of these best describes your present state of health? *I must continue taking the drug since I still have symptoms.I have a complicated and severe medical condition that require close monitoringSTOP! You are not a candidate for telemedicine due to the severity of your illnessPreviousNextWhich of these medicine categories do you want a refill on? IMPORTANT *AntibioticBlood pressure-lowering medicationcardiac (heart) medicationOral anti-diabetic (pills for diabetes)injections of insulin or other diabetes medicationsDrugs that decrease lipids or cholesterolMedicine for the thyroidfungicides like fluconazoleDiabetic medicationsClotting agentsOtherPlease specify *PreviousNextWhat condition(s) of the heart do you have? *PreviousNextWhat has your average fasting blood glucose (sugar level) been over the last seven days? *Less than 80Between 80- 140Between 140 - 170Over 170Over 200I do not keep an eye on my blood sugar.PreviousNextWhy do you take water pills or diuretics? *I do not use water pills or diurecticsLeg swelling or edemaHeart condition such as CHFTrouble breathingLymphedemaFor weight lossLiver disease or ascitesOtherOther reasonsPreviousNextDo you use blood thinners? If yes explain why you use itPreviousNextWhich of these other drug classes are you interested in repurchasing?Asthma or COPD inhaler or aerosolAntivirals such as HIV or herpes drugsPsychiatric drugOther classes not listed abovePlease specifyPreviousNextChoose a justification why your primary care physician or a specialist cannot renew your prescription. *I don't have a physician.The medical facility is closed or full.I am unable to pay the doctor's fees.My routine is very hectic.I lack insuranceBefore my next doctor's appointment, I'll run out of refills.My physician declined to renew my medication.Please give the reason for your doctor's refusal to renew your prescription.PreviousNextWhat number of prescriptions would you like to renew today? *OneTwoThreeFourFive or moreAt one time, we can only recommend up to 4 drugs. Select 4 and complete a different intake form for the remaining questions.PreviousNextEnter the name, dosage, and route of administration of the medicine (for instance, lisinopril 10 mg. One pill each morning) *PreviousNextEnter First and second medication's name, dosage, and prescription strength, and method of administration (for instance, lisinopril 10 mg. One pill each morning) *PreviousNextList each of the three medications' brand, strength, and dosage one at a time (for instance, Lisinopril 10 mg. One pill each morning)PreviousNextList each of the four medications' brand, strength, and dosage one at a time (for instance, Lisinopril 10 mg. One pill each morning)PreviousNextList EVERY medical condition for which you take the required refill medication (IMPORTANT).PreviousNextDo you tolerate the prescribed medication(s) without experiencing any unfavorable side effects? *Yes! My medication(s) have no severe negative effects.No! I experience significant side effects of one or more of my medicationsSTOP! Remove the medication with adverse side effect to proceedPreviousNextWhen did you last administer or take your medication(s)? *Today, I took my prescribed drug(s).I didn't take any of my medications in the previous 24 hours.PreviousNextWhy did you miss your prescription dose in the previous 24 hours?- Pick the best response. *I'm out of replacements.My prescription is missing.I don't need to take the medicine every day.PreviousNextWhen did the refills run out? *Less than 7 daysIn the last 1 to 2 weeksOver 1 monthPreviousNextWould you like to alter your medication(s) in any way? *No Changes! Just refillYes, I would like to CHANGE the doseEnter the medication(s) that require dose changes?PreviousNextWhat modifications would you like to ask for? (To prevent delays, be specific and clear.) *PreviousNextHow would you like your prescription(s) to be verified? *I'll post my prescription medication bottles.I'll upload a list of my prescription drugs from my pharmacist or doctor.I've previously had the medication(s) prescribed to me by Reddydoc.Telephone my pharmacy (This choice can cause the filling procedure to take longer.)Type the pharmacy's name and phone number (check that the pharmacy has your prescription record to prevent delays).PreviousNextSend Pictures of Rx Bottle or Medication ListFront & back views to display your name and dosage instructions Click or drag files to this area to upload. You can upload up to 3 files. PreviousNextHow do you keep an eye on your heart rate and blood pressure at home? *House blood pressure monitorAt the drugstore or pharmacyA medical facility or a clinicI don't regularly check my blood pressure or heart ratePreviousNextRx Refill Terms and Condition Labs may NOT be required for first time users. However, I understand that Reddydoc may require labs in the near future if neededI understand that Reddydoc can only prescribe a small quantity (30 days or less) of potentially dangerous drugs such as insulin, blood thinner, seizure drugs, Lasix and some antibioticsI understand that Reddydoc does NOT prescribe controlled substances or sedating medications such as muscle relaxant or gabapentinPreviousNextFollow-up agreement *I understand and agree to follow up with a doctor in-person or go to the ER immediately if the patient's symptoms persist or worsenPreviousNextSelect Preferred Refill Plan(Medication NOT included, you still need to pay for your Rx at the PHARM *($39.99) BASIC: online visit (30 day supply sent to your PHARMACY with NO REFILLS)($54.99) ADVANCED: online visit (90 day supply sent to your PHARMACY with NO REFILLS)($69.99) ADVANCED +: online visit (30 day supply sent to your PHARMACY with 3 REFILLS)($79.99) PREMIUM: online visit (90 day supply sent to your PHARMACY with 1 REFILL)($50.00) QUARTERLY SUBSCRIPTION PLAN *BEST VALUE: online visit 90 day supply sent to your PHARMACY automatically every 90 days until cancellePreviousNextChoose the lab tests you have performed during the previous 12 months.Kidney function test (such as creatine or BUN)Liver function test (ALT, AFT)Hba1cTSHLipid panel (such as Cholesterol, TG)Electrolytes (such as Potassium, Sodium)CBC (such as Hemoglobin, hematocrit, platelet)STD or HIV testOther lab testsNone of the aboveOther lab testsPreviousNextWould you like to give our doctors your lab results? The patient's name, birthdate, and test date must be clearly displayed. *Yes! I'll attach my lab result next (Recommended)Yes! I'll email my result to provider@www.condition.reddydoc.comI do NOT have a copy of the test resultNO labs or blood test done in the last 6 to 12 monthsPreviousNextIf you use a drug that needs to be monitored in a lab, how would you prefer to proceed today? *Refill my prescription and refer me for lab test in the futureRefer me for labs before you refill my medicationPrescribe a short supply and I'll follow up with my doctor for labsI will NOT comply with lab testingPreviousNextPlease submit pertinent laboratory results or pertinent medical records. You must be able to see your name and birthdate.Front & back views to display your name and dosage instructions (copy) Click or drag files to this area to upload. You can upload up to 3 files. PreviousNextLeave a comment or feedback (Optional)PreviousNextGiven the limitation of telemedicine, we encourage an in-person follow-up if your medical concerns do not resolve after a telemedicine visit. *I agree to follow-up for an in-person re-evaluation with a local doctor as neededI have an upcoming appointment with my doctorWhen is your next doctor's appointment? *PreviousNextSupplemental Service Disclosure *We prescribe FDA-approved medications and follow evidence based medical guidelines. In some cases, the initial medication may not completely eradicate your symptoms or cure the infection. In this situation, similar to other clinics and doctor's offices, the patient is responsible to pay for the follow-up visit and repeat treatment.I have been informed that it's my responsibility to handle prescription medication with care and store it in a safe environment. There's an additional fee to reissue lost or misplaced medications.I understand that there is a processing charge of $20 when a request is made for an excuse note or doctor's letterI understand that there's a $50 surcharge when a request for prior authorization or peer to peer review is required by your insurance or payerPreviousNextRefund Policy Terms *I am aware that I have a full refund option at any point before ReddyDoc sends my prescription. Our consultation charge is no longer refundable once a medical professional has finished your treatment plan, submitted your prescription to your pharmacy, requested a test, or fulfilled your request.We aim to finish every consultation in under two hours. However, insufficient medical data, technical issues, or a high patient load may cause the turnaround time to be prolonged. Be prompt if you must cancel due to delays. If your request for a refund is made after we have sent your prescription to the pharmacy or finished the treatment plan, the consultation fee is NOT refundable.I am aware that the consultation cost is non-refundable in the event that my body does not respond to therapy or if the prescribed medicine does not entirely cure my disease or eliminate all of my symptoms. You are welcome to submit a second consultation for review.PreviousNextWould you wish to offer a Power of Attorney or an Emergency Contact? *Yes, I want to add a power of attorney or an emergency contact.No! Please under no circumstances disclose my medical information to my relatives or friends.PreviousNextEnter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *PreviousNextDo you want to give the person who handles emergencies access to your medical records? *Yes! I hereby authorize ReddyDoc and its staff to provide my emergency contact with access to my medical records.No! I DO NOT authorize anyone to access my medical record or act on your behalf other than ReddyDoc, its designated agents, and employees.PreviousNextEnter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *PreviousNextPharmacy Name *Pharmacy Address *Pharmacy Phone *PreviousNextBilling Address *Address Line 1Address Line 2CityState / Province / RegionAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePreviousNextConsultation feePrice: $34.99Stripe Credit Card *Submit