Pediatrics Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 34Email *NextFirst Name *Last Name *PhonePreviousNextDate of Birth *Confirm Date of Birth *Check to confirm date of birthGender *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 IslanderHispanicWhiteOtherOtherMarital 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 MexicoBackNextAre you experiencing life-threatening symptoms or a medical emergency? *YesNo life-threatening symptomsUnfortunately we do NOT treat life-threatening conditions online. Please call 911BackNextAre you alert and oriented? *YesNo-STOP! You must be alert and oriented to proceedBackNextAre you allergic to any drug? *No drug allergies (NKDA)YesWhat medications are you allergic to?BackNextDo you have any underlying medical conditions? *I do NOT have any chronic medical or psychiatric conditionsHeart diseaseHypertensionLiver diseaseKidney diseaseDiabetesHigh cholesterolThyroid disorderPsychiatric conditionHIV/AIDSOther ConditionOther conditionBackNextType of heart disease *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 *BackNextWhat's your average blood pressure reading? *Normal (Less than 140/90)Elevated (Less than 160/100)Uncontrolled (Over 160/100)BackNextType of liver diseaseBackNextType of kidney disease *Kidney stonePolycystic Kidney DiseaseKidney infection or cystNephritis or nephropathyKidney cancerElevated creatinine or low GFRSolitary or Single-functioning KidneyOtherList other kidney disease *BackNextHow 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)BackNextLast 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 disorderBackNextSelect applicable psychiatric condition *DepressionAnxietyPanic disorderBipolar or mood disorderSchizophrenia or psychosisPTSDEating disorderOCDOtherPlease specifyBackNextAre you currently taking any medication? *NoYesEnter medication name *BackNextMedication Disclosure Clause *I hereby certify that I am NOT currently taking any medication including OTC or supplements, and agree to indemnify and hold Callondoc 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 informationBackNextSelect Applicable Social History Non-smokerDrink Coffee multiple times a dayCurrent smoker (Vape, cigarette or tobacco)Former cigarette or tobacco usePrescription drug addictionBackNextLast visit to a doctor for in-person visit? *In the last 3 monthsIn the last 3 to 6 monthsIn the last 6 to 12 monthsOver a year agoNever met a doctor in-personBackNextSelect the reason for today's visit *Sore throat or URISkin disorderEar infectionSinus infectionFeverUTI or bladder infectionEye infectionOtherOther reasonsBackNextBriefly describe the patient's symptoms *BackNextWhich of these symptoms are present? Check all that applies *Sore throatWhite patches or pus in the back of your throat (tonsils)Pain when swallowing, and even speaking?Swollen and painful lymph nodes on the front sides of your neckEar acheNone of the above symptomsBackNextDoes the patient have a fever? *Lower than 100.4°F or 38°COver 100.4°F or 38°CNo feverBackNextDoes the patient have a cough? *Yes, dry coughYes, coughing up white or clear sputum/phlegmYes, coughing up yellow or green sputum/phlegmBarking coughWhooping coughBloody coughNo coughBackNext Do you have a discharge or drainage from your ear? *Yellow/green drainageClear/watery drainageBlood draining from the earNo ear drainageBased on this selection you're not a candidate for our treatment. See your doctorBackNextFollow-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 worsenBackNextYou may attach supporting images or medical records below (Optional)File Upload Click or drag a file to this area to upload. BackNextLeave a comment or feedback (Optional)BackNextSupplemental 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 payerBackNextPharmacy Name *Pharmacy Address *Pharmacy Phone *BackNextBilling 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