Covid 19-RX – Reddydoc

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Email *

First Name *

Last Name *

Phone

Date of Birth *

Confirm Date of Birth

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

We do not, unfortunately, treat life-threatening disorders. 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 chronic medical or psychiatric issues
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 *

What is the average reading of your blood pressure? *

Normal (Less than 140/90)
Elevated (Less than 160/100)
Uncontrolled (Over 160/100)

Type of liver disease *

Type of kidney disease *

Kidney stone
Polycystic Kidney Disease
Kidney infection or cyst
Nephritis or nephropathy
Kidney cancer
Elevated creatinine or low GFR
Solitary or Single-functioning Kidney
Other

List other kidney disease *

How 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)

Last thyroid test *

Normal TSH level in the last 12 months
Elevated TSH (or low T4 or T3) level
Low TSH (or low T4 OR T3) level
No thyroid lab test in the last 12 months
I have symptoms of abnormal thyroid disorder

Select applicable psychiatric condition *

Depression
Anxiety
Panic disorder
Bipolar or mood disorder
Schizophrenia or psychosis
PTSD
Eating disorder
OCD
Other

Explain Other psychiatric condition

Are you currently taking any medication? *

Enter medication name *

Medication 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 information

Choose the relevant surgical history

No surgical history
Appendectomy
Breast augmentation
C-section
Gallbladder surgery
Hysterectomy
Hernia repair
Mastectomy
Surgery involving joints
Tonsillectomy
Various Surgeries

List any more operations you had in the past.

Choose Relevant Social History

Non-smoker
Take many cups of coffee every day.
Smoker nowadays (tobacco, vape, or cigarettes)
Prior smoking or tobacco use
Addiction to prescription drugs
Alcohol-dependence
Drug use (cocaine, marijuana, etc.)

When was your last in-person visit to the doctor? *

Within the past three (3) months
Within the last three (3) to six (6) months
Within the last six (6) to twelve (12) months
More than a year ago
Never met a doctor in person

How old are you? *

Less than 50 years old
Fifty years or more

You must have an underlying medical condition and risk factors for developing covid complications to Qualify.

Which of these conditions puts you at risk for covid-19 complications? *

Patient over 50 years old
Obese
Heart Condition
Kidney Diseases
Diabetes
Hypertension
Obesity
Immune system disorders as lupus, AIDS, and cancer
Respiratory conditions such asthma, COPD, sleep apnea, and cystic fibrosis
Neurological disorders like dementia and Alzheimer's
Mental health issues
A persistent medical condition
None of the dangers mentioned above

Do you have a diagnosis and medical records? *

Yes, I will upload a medical record together with other documents (such as lab results, a prescription, a doctor's letter, etc.)
I have no medical records to back up this diagnosis.

STOP! To prove a diagnosis, you must attach a medical record or prescription. The COVID test does not pose a risk.

Upload a copy of your medical record for the underlying condition; it must show your full name and date of birth in order to qualify. Medical records or prescriptions must be uploaded *

Click or drag a file to this area to upload.

Status of COVID immunization *

Fully Vaccinated
Partially Vaccinated
Unvaccinated

Did your COVID-19 test come back positive? *

Yes
No! I did not have a COVID-19 positive test.

STOP! You must test positive for COVID-19 to be eligible for prescription medication.

When did your COVID-19 test come back positive? *

Today
Yesterday
2 days ago
Within the last 5 days
Over 5 days ago

STOP! Treatment is effective if administered within 5 days of an infection

Clinical Eligibility *

I hereby attest that, within the last five days, I tested positive for COVID-19.
Recognize that Paxlovid, a COVID drug, is ineffective in patients with covid-negative status and after 5 days following a positive test

Choose the day that your COVID-19 test result came out positive. *

Have you been exposed to other respiratory infections such as strep, influenza, or TB? *

Yes
No, I have not come into contact with any other respiratory illnesses like strep or influenza.

Which infection were you exposed to? *

Are you presently experiencing COVID-19 symptoms? *

I do (I have mild to moderate symptoms).
I have significant symptoms of COVID-19.
I do not have signs of COVID-19.

STOP! Patients with mild to moderate symptoms might consider a prescription. Molnupiravir and Paxlvod are ineffective for treating severe symptoms.

How long have you had COVID symptoms? *

Less than 7 days
In the last 7 to 14 days
Longer than 14 days
Over one month

Which of these COVID-19 signs are you presently dealing with? *

Loss of flavor or scent
Flu-like symptoms
Fatigue or tiredness
Diarrhea
Body ache
Severe shortness of breath and difficulty breathing
Poor appetite
Chest pain
Chills
Bluish lips or face
Low oxygen level
Other symptoms

Other symptoms

STOP! We do not treat severe cases online. Please call 911 or proceed to the nearest emergency room

Are you feverish? *

What is your current temperature? *

Lower than 100.4°F or 38°C
Over 100°F
I feel warm

Do you have any of these respiratory symptoms? *

Throat pain
White patches or pus in the back of the throat
Pain during speaking and swallowing
A blocked nose
Meaty or enlarged red tonsils
Drooling
Uncomfortable and swollen lymph nodes in the neck
Cough
I have other COVID-19 symptoms

Other COVID-19 symptoms? Explain *

Are you currently taking any prescription or home remedies medication including OTC drugs for your COVID symptoms? *

STOP! We highly recommend home remedies or OTC drugs for symptom relief before initiating prescription treatment

Which natural treatments or prescription drugs do you use to treat your COVID symptoms? *

Do the natural treatment or over-the-counter medicine seem to be helping your symptoms? *

Yes, there has been massive improvements in my symptoms.
No, my symptoms are becoming worse.

STOP! Please continue your home remedy.

Which medication from this list would you like us to recommend for COVID-19? *

I will leave that up to the doctor. (Recommended)
Molnupiravir (Lagevrio) - FDA-approved for COVID
Paxlovid (nirmatrelvir -ritonavir) - FDA-approved for COVID

If Paxlovid is determined to be hazardous or harmful to you, would you prefer us to prescribe Lagevrio instead? *

If Paxlovid is hazardous or harmful for me, I thus give my approval to the alternative drug.
DO NOT recommend a different drug.

STOP!. We will not recommend a drug that might be dangerous for you.

Alternative Drug Consent and Agreement *

I acknowledge that Lagevrio is an FDA-approved substitute for treating COVID-19.
In the event that Paxlovid is deemed dangerous or perhaps hazardous to my health, I thus give Reddydoc permission to prescribe Lagevrio.
I am aware that Reddydoc will not provide Paxlovid if it has been determined to be hazardous, harmful, or to interact negatively with any of my current drugs.
I am aware that after Reddydoc has prescribed Lavegrio, it CANNOT modify the prescription to Paxlovid for safety concerns, and that the consultation fee is non-refundable once the prescription has been delivered to the pharmacy.

Do you want extra medication(s) to treat your symptoms? *

Tessalon Perles (Benzonatate) Tablet for cough
Albuterol inhaler
No extra prescription is required.

Do you have a copy of an At-Home Swab Stick or a POSITIVE COVID-19 test result to upload? *

Yes, I will post the results of the positive COVID-19 test.
Yes, I will post a result from a successful at-home COVID-19 swab stick.
No

STOP! To receive therapy, a positive test result must be uploaded.

Provide a copy of a positive COVID-19 test result (a positive result is required to qualify). *

Click or drag a file to this area to upload.

Warning and Requirement for Treatment *

I am aware that it is against the law to upload test results that are fake or inaccurate.
I am aware that it is against US law and treatment recommendations to falsely represent one's COVID status or to give false medical information in order to obtain a Paxlvoid prescription online
I hereby attest that the test result submitted was obtained within the last five days and is positive for COVID-19.

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

Click or drag a file to this area to upload.

(Must show your face and full body)

Treatment Standards *

I am aware that patients with positive COVID results, symptoms, and underlying high-risk medical conditions are the ONLY ones for whom Paxlovid and Lagevrio are recommended. Paxlovid and Lagevrio's unfavorable or side effects have not been thoroughly researched.

Only patients with substantial risks are eligible for treatment. Give us a convincing justification for approving your prescription request *

Preferred means of communication *

Email
Text(sms)
Phone call

How did you discover our website? *

Hold Harmless Agreement - All boxes must be checked *

I acknowledge that the medical information I have provided on this intake form is complete and accurate, and I thus accept full responsibility for any harm or damages that may result from any missing or inaccurate information
By taking Paxlovid or Lagevrio, I hereby release Reddydoc and its staff from all liability for loss, damages, lawsuits, costs, and other expenses.

IMPORTANT: Disclosure of Medication List - Check All *

I have been told that Paxlovid interacts negatively with a variety of drugs.
I hereby attest that I have not left out any of my current prescriptions in order to receive a prescription for Paxlovid.
I am aware that giving inaccurate or incomplete medical information could be dangerous and detrimental to my health.

Read the Online Treatment Eligibility and Refund Policy carefully.

I am aware that Reddydoc only offers COVID-19 treatment to patients who are physically residing in the United States
I am aware that getting a prescription for a patient who is not actually in the US is against the law.
I am aware that taking Paxlovid or Lagevrio while traveling abroad is illegal.
I am aware that violating our policy by providing false information to get a prescription may result in cancellation with NO reimbursement.

Do you have any further details you would like to present to the doctor today? (Optional)

Given 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 needed
I have an upcoming appointment with my doctor

When is your next doctor's appointment? *

Supplemental 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 letter
I understand that there's a $50 surcharge when a request for prior authorization or peer to peer review is required by your insurance or payer

Refund 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.

Would 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.

Enter the Full Name and Birthdate of the Emergency Contact (IMPORTANT). *

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: $64.99

Stripe Credit Card *