Asthma – Reddydoc

Please enable JavaScript in your browser to complete this form.

- Step 1 of 45

Email *

First Name *

Last Name *

Phone

Date of Birth *

Confirm Date of Birth *

Check to confirm date of birth

Gender *

Weight *

Height *

Race

Other Race *

Marital Status

Who is the patient? *

What disease are you suffering from? *

Select Your Location *

Let's match you with an authorized medical professional in your state.

Consent 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 information

Authorization 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.

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.

Do you have a life-threatening symptom or a medical emergency? *

Yes
No life-threatening symptoms

Unfortunately we do NOT treat life-threatening conditions online. Please call 911

Are you focused and alert? *

You must be focused and aware.

Are you allergic to any medications? *

No, there are no medication allergies (NKDA).
Yes

What drugs do you have an allergy to? *

Do you have any underlying medical issues? *

I have no underlying medical issue
Heart disease
Hypertension
Liver disease
Kidney disease
Diabetes
High cholesterol
Thyroid disorder
Psychiatric condition
HIV/AIDS
Other Condition

List any further health issues you may have.

Type of heart issue *

Coronary Artery Disease (CAD) or heart attack
Heart Valve Disease
Arrhythmias or abnormal heartbeat
Heart Failure or CHF
Congenital Heart Disease
Cardiomyopathy (Heart Muscle Disease)
Pericardial Disease
Other

List other heart conditions that you have *

Are you currently taking any medication? *

Enter medication name *

Select Applicable Surgical History *

No surgical past
Appendectomy
Breast augmentation
C-section
Gallbladder-surgery
Hysterectomy
Hernia repair
Mastectomy
Orthopedic surgery
Tonsillectomy
Other surgery

Select Relevant Social History *

Non-smoker
Drink coffee multiple times a day
Current smoker (Vape, cigarette or tobacco)
Former cigarette or tobacco use
Prescription drug addiction
Alcohol-dependence
Illicit drug use (marijuana, cocaine etc)

Last visit to a doctor for in-person visit? *

In the last 3 months
In the last 3 to 6 months
In the last 6 to 12 months
Over a year ago
NEVER see a doctor in-person

Do you have any of the following signs and symptoms? *

Trouble breathing
Chest pain
Uncontrollable cough
Bloody cough
Feeling panicky or Sweating
I am NOT experiencing an acute asthma attack

Do you have any of these conditions?

COPD
Asthma
Cystic fibrosis
Other lung diseases
Chronic smoker (Cigarette or Tobacco)
Heart disease
Kidney disease or Liver disease
None of these medical conditions

Write any other medical conditions not listed above

Tell Us About Your Asthma *

As a child
As an adult
I have NOT been diagnosed with asthma

Which of these applies? *

My asthma is controlled with current medication(s)
I visit the ER or doctor frequently for asthma attacks
I have been intubated in the past for asthma exacerbation
My asthma is not controlled with current medications
None of the above apply to me

How many asthma attacks do you experience per YEAR that requires steroid tablets use or ER visit? Enter N/A if none. *

Does your asthma interfere with your normal activities?

Minor interference
Significant Limitation
I have asthma symptoms throughout the day or need inhaler several times per day
My asthma does NOT interfere with my lifestyle

How many days a week do you have asthma symptoms and need to use your inhaler? *

Which of the following triggers your asthma (risk factors) *

Exercise-induced
Allergies
Smoking, including second hand exposure
Stress
Lack of asthma medication
Spontaneous attack without a specific trigger

If applicable, briefly explain your last doctor visit

Reason for this Visit *

Start asthma treatment
Refill my asthma medication

For treatment, select preferred medicine from the following FDA approved asthma treatment *

Albuterol Inhaler
Xopenex inhaler
Albuterol nebulizer solution
Albuterol nebulizer solution
Singulair
No preference

For refills, write asthma medications you would like to refill today

Medication name, dose and frequency (e.g ProAir HFA 108 mcg 2 puffs every 4 hours) *

Select Prescription Refill Quantity (Medication not included)

Prescription bottle each with one refill
Prescription bottle each with 2 refills
Prescription bottle each with 3 refills
1 prescription bottle each with 5 refills

Important: Paying for medication *

I understand that I still have to pay for the medicine at my pharmacy

Upload any medical records, test results, pathology reports, or photographs that are clinically relevant.

File Upload

Click or drag files to this area to upload. You can upload up to 3 files.

NOTE* medication NOT INCLUDED, you still need to pay for your medication at the PHARMACY

Select Preferred Treatment Plan

Peace of mind knowing your basic healthcare is covered

Membership Agreement

I certify that I am the authorized user of this payment card and I authorize ReddyDoc.com to charge the agreed initial consultation fee and recurring subscription fee to my payment card every 30 to 90 days.

I understand that this authorization will remain in effect, and accept the responsibility for all recurring charges until I request a cancellation on my PATIENT PORTAL (DASHBOARD).

If the payment fails for any reason, I understand that ReddyDoc's services and prescriptions refill will be terminated immediately until the issue is resolved. In addition, I agree to notify ReddyDoc.com of any changes to my payment information a few days prior to the billing date.

I understand that this authorization will remain in effect, and accept the responsibility for all recurring charges until I request a cancellation on my PATIENT PORTAL (DASHBOARD).

I understand that this plan does not cover the medication and I still have to pay the pharmacy to dispense the medications.

Refund and Cancellation Policy

I understand that the initial consultation fee is non-refundable after the prescription has been sent to a pharmacy or the consultation status is marked 'COMPLETED'. You may cancel before your medication is ePrescribed.

I understand that the recurring subscription fee is NON-REFUNDABLE under any circumstances AFTER the billing date.

You can cancel the membership plan anytime at least 48 hours before the next billing cycle, subject to the terms of our billing cycle.

I understand that the acceptable method of cancellation is on my Patient Portal (Dashboard.) Please do NOT cancel via email, phone or text.

Amount: $30 Charged Today And Every 3 Months

By clicking on Next, I acknowledge that I have read Plan Benefits and agree with the Subscription Terms and agreement.

Do 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.

Pharmacy Name *

Pharmacy Address *

Pharmacy Phone *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Consultation Fee

Price: $34.99

Stripe Credit Card *