Dental infection – Reddydoc

Please enable JavaScript in your browser to complete this form.

- Step 1 of 58

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 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's your average blood pressure reading? *

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

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

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 addiction

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

Are you the patient in need of medical treatment? *

Yes, I'm the patient in need of treatment
I'm filling out this consultation on behalf of the patient

STOP! PATIENT ALONE MUST COMPLETE THIS FORM

What is the main reason you are here? *

Tooth infection
Tooth decay
Dental abscess
Cold sore (Herpes 1)
Gum infection
Thrush (Fungal infection)
Bleeding gum
Canker sore
Bad breath (Halitosis)
Oral STD (Chlamydia or Gonorrhea)
Other

For others, please be as specific as possible about your symptoms and the nature of your visit. *

Have you used any supplements or medications to treat your symptoms? *

Which drugs have you tried? *

What time did your symptoms begin? *

Less than 7 days
Lest than 1 month
Over 1 month
Longer than 3 months

Do any of these teeth symptoms apply to you? *

Toothache
Cracked or Broken Teeth.
Abscess tooth
Sensitive teeth
None

Do you exhibit any of these gum-related symptoms? *

Gum abscess
Bleeding Gums
Gum swelling
Sore Gums
Pus drainage
None

Which teeth are impacted? *

One tooth
1 - 3 teeth
More that 3 teeth

Do you have any of these jaw or facial symptoms? *

Jaw pain
Jaw swelling
Facial swelling
Facial pain or pressure
Facial paralysis
None

How serious do you think your symptoms are? *

Mild symptoms
Moderate and stable symptoms
Severe symptoms (Medical emergency)

STOP! Unfortunately, we are unable to provide online treatment for severe symptoms. Visit a local dentist or physician

Do any of these additional signs apply to you? Carefully read *

Lip blisters or ulcer
Fever
White deposit on the tongue
Dry mouth
Difficulty swallowing fluid
Difficulty chewing food
Oral Piercing Infection
None of the above

Are you feverish? *

Low grade fever
High fever

STOP! Sadly, this indicates that you have a serious dental issue. Visit a doctor right away, please.

Which of these dental ailments have you previously had? *

Dental procedures (such as extractions and implants)
Cavity
Chronic gum diseases
Dental or facial trauma or injury
Tooth decay
Other
No significant past dental disorders

List other dental conditions that you have

When was the last time you visited an orthodontist or dentist? *

In the last 6 months
In the last 6 to 12 months
Over a year ago

Give a brief description of your most recent dental or orthodontic experience. *

Which drug from this list would you like us to recommend to you? *

Amoxicillin-clavulanate (Augmentin)
Amoxicillin
Metronidazole
Amoxicillin PLUS metronidazole
Clindamycin for 5 days
I'll let the doctor decide

Do you require any of these extra medicines? *

Ibuprofen 400 mg for pain
Diclofenac for pain
Naproxen for pain
Sodium fluoride toothpaste to prevent cavities
Mouthwash for Gingivitis
No additional Rx needed

Have you scheduled a dental or orthodontic appointment soon? *

When is your next appointment (Select a date) *

Important Information *

If my problems continue or get worse, I consent to see a doctor, dentist, or go to the ER.
I am aware that the medication is not covered by the consultation fee. The cost of the prescribed meds at my pharmacy is still mine to pay.
I am aware that a general practitioner, NOT a dentist or an orthodontist, will examine this intake form.

Please submit at least two distinct pictures of the afflicted teeth, face, or dental area. *

I will upload pictures of the affected area on the next screen
I sent reddydoc images at provider@www.condition.reddydoc.com.

Upload at least 2 clear images of the affected face, teeth or dental area

File Upload

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

Disclaimer *

I consent to sending Reddydoc providers pictures of my condition via email or text in order to receive care. I acknowledge that if I don't deliver the photographs or submit them in a timely manner, my processing time will be extended.

Leave a comment or feedback (Optional)

Follow-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 worsen

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: $45.99

Stripe Credit Card *