Heartburn Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 61Email *NextFirst Name *Last Name *PhonePreviousNextDate of Birth *Gender *MaleMaleFemaleWeight *Height *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 RaceMarital 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 (copy) *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 symptomsUnfortunately we do NOT treat life-threatening conditions online. 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).YesPreviousNextWhat drugs do you have an allergy to? *PreviousNextDo you have any underlying medical issues? *I have no chronic medical or psychiatric issuesHeart diseaseHypertensionLiver diseaseKidney diseaseDiabetesHigh cholesterolThyroid disorderPsychiatric conditionHIV/AIDSOther ConditionPreviousNextOther conditionPreviousNextType of heart issue *Coronary Artery Disease (CAD) or heart attackHeart Valve DiseaseArrhythmias or abnormal heartbeatHeart Failure or CHFCongenital Heart DiseaseCardiomyopathy (Heart Muscle Disease)Pericardial DiseaseOtherPreviousNextList other heart conditions that you have *PreviousNextWhat's your average blood pressure reading? *Normal (Less than 140/90)Elevated (Less than 160/100)Uncontrolled (Over 160/100)PreviousNextType 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 disorderOCDOtherNonePreviousNextOther conditionPreviousNextAre you currently taking any medication? *NoYesPreviousNextEnter 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 Relavant Surgical History *No surgical pastAppendectomyBreast augmentationC-sectionGallbladder surgeryHysterectomyHernia repairMastectomyOrthopedic surgeryTonsillectomyOther surgeryPreviousNextList any other past surgeries PreviousNextSelect 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) monthsMore than a year agoNEVER met a doctor in personPreviousNextHave you received an evaluation from a medical provider for heartburn?YesNo! I have NOT see a doctor for heartburnPreviousNextEnter the medication used and treatment outcome *PreviousNext Which of these tests have you taken? *EndoscopyH-pylori testBarium swallow testX-rays of your upper GI tractEsophageal manometryAmbulatory acid (pH) probe test.None of the above diagnostic testsPreviousNextIf applicable, explain the test resultPreviousNextWhich of these heartburn symptoms do you experience? Burning sensation in your chest (heartburn)IndigestionBackwash (regurgitation) of food or liquidTrouble swallowing (dysphagia)Sore throat and hoarsenessUpper abdominal painSensation of a lump in your throatNauseaCoughOtherPreviousNextDescribe your symptoms or provide additional information about your condition *PreviousNextWhen did the symptoms begin to manifest? *Less than one weekLonger than one weekLonger than 1 monthLonger than 3 monthsPreviousNextHow frequently do you encounter these symptoms? *This is my first episodeOccasionally or intermittentlyFrequentlyDailyPreviousNextDescribe the severity of your heartburn symptoms. *Mild symptomsSevere symptomsModerate symptomsPreviousNextWhich of these causes or risk factors for heartburn apply to you? *SmokerOverweight or obeseEating large meals or eating late at nightEating certain foods (triggers) such as dairy, spicy, fatty or fried foodsMedicines for asthma, high blood pressure, allergies, painkillers, sedatives and anti-depressantsDrinking beverages, such as alcohol or coffeeI have a connective tissue disorderPregnancyHiatal herniaOtherPreviousNextBriefly explain the cause of your symptoms *PreviousNext Do you have any of these additional conditions? *Chest painUncontrollable vomitingBloody stoolAnemiaUnexplained weight lossGastrointestinal cancer in a first-degree relativePersistent WheezingNone of these conditionsSTOP! You've selected a severe symptom. Send us an email to info@www.condition.reddydoc.com for further assistancePreviousNextNature of chest painHeartburn (Burning pain located in the middle of the chest)Chest pain with difficulty breathingChest pain radiating to left sideHeaviness on my chestCardiac pain (feels like a heart attack)STOP! You may be experiencing a heart attack. Please call 911 immediatelyPreviousNextDo you have any of these symptoms? Feeling dizzy with sensation of passing outVomiting bloodI have a feverNone of these symptomYou're not a candidate for treatment. See your doctorPreviousNext Which of these medications would you prefer us to prescribe?Pantoprazole (Protonix)Cimetidine (Tagamet)Famotidine (prescription strength)Esomeprazole (prescription strength)Sucralfate (for stomach ulcer)Omeprazole (prescription strength)Dexlansoprazole (Dexilant)I'll let the doctor decidePreviousNextChoose your preferred refill plan.($39.99)BASIC: online visit (30 day supply sent to your PHARMACY)($49.99)ADVANCED: online visit (90 day supply sent to your PHARMACY)($50.00)QUARTERLY SUBSCRIPTION PLAN *BEST VALUE: online visit 90 day supply sent to your PHARMACY automatically every 90 days until cancelledPreviousNextFinancial Agreement *I acknowledge that the consultation fee charged by Reddydoc is for the medical provider's services, which include reviewing and prescribing medications. I am aware that I will also be responsible for the cost of the medication at the pharmacyI acknowledge that the consultation fee is non-refundable once the medical provider has transmitted the medication to my pharmacy.PreviousNextWould you like to upload images of the affected area or supporting medical records to the medical provider? *YesNoPreviousNextPlace pictures and medical records online Click or drag files to this area to upload. You can upload up to 3 files. PreviousNextDo you have any additional information you'd like to share with the medical provider today? (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 TermsI 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 my behalf other than ReddyDoc, its designated agents, and employees.PreviousNextEnter the Full Name and Birthdate of the Emergency Contact.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