General Anxiety – Reddydoc

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Email *

First Name *

Last Name *

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Date of Birth *

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Gender *

Weight *

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Marital Status

Who is the patient? *

What disease are you suffering from *

Select Your Location *

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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

Other 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

Which of these mental illnesses have you been identified with? *

Depression
Anxiety
Bipolar disorder
PTSD
OCD
Insomnia
Schizophrenia
ADHD
None of the above psychiatric conditions
Add more

Please list any further psychiatric conditions you may have.

Have you had a mental health professional review you in the past year? *

Give a brief explanation on how it went

In the last 3 months, have you experienced symptoms of depression? *

Which of these symptoms do you have? *

Depression and hopelessness
Little enthusiasm towards accomplishing things
Having negative feelings toward yourself
I've had the idea that I'd be better off dead.
Sleeping issues (insomnia) or excessive sleepiness (hypersomnia)
Excessive concern for life's problems
Feeling worn out or low on energy
Hallucinations (imaginary sounds, sensations, or visions)
Lack of appetite
Feeling tense, fearful, or unstable
Anxiety over social encounters, being watched, and public displays
None of the above
Other

Other symptoms *

What is the main purpose of today's consultation? *

Treatment of depression
I need more of my psychiatric meds.
Change to a different drug
The dosage of a drug.

Enter the names, doses, and instructions for the psychiatric medications you want to reorder. *

What dosage changes are you looking at? Give thorough directions

How frequently do you feel depressed? *

Rarely
Sometimes (occasionally)
Almost every day

Do you find it challenging to carry out your everyday tasks while you're depressed? *

It can be challenging to live a normal life.
I find it very challenging to manage my mental health condition.
My mental health has no impact on how I live my life.

Which of these have you personally experienced? *

Stressful circumstances
Physical or sexual abuse
Loss of a family member or close friend
Either emotional abuse or neglect
Divorce or a split from one's spouse
Financial hardship, property loss, and employment loss
None of the aforementioned

Which of these ideas best describes you? *

I have a detailed strategy to harm myself or other people.
I've done a lot of things to injure myself or other people.
I have access to weapons or other potentially harmful equipment.
I DO NOT consider harming myself or others.

STOP! Please call 911 or proceed to the ER immediately

Which of these professionals have you consulted for an assessment or treatment of your mental health? *

Psychiatrist
Therapist
Psychologist
Counselor for mental health
Additional mental health specialists
Family physician (PCP)
None

Xanax, Ativan, or any other controlled substances are not prescribed by us.

Controlled Substance *

I've been told that Reddydoc doesn't recommend controlled substances or excessively sedative medications.

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

Fluxetine (Prozac). Ideally, if you're sensitive to weight gain
Lexapro is escitalopram.
Effexor (Wellbutrin)
Effexor with venlafaxine
Fluoxetine (Sertraline)
Cymbalta (duloxetine)
Paxil (paroxetine)
Citalopram (Celexa)
Please reorder my prescriptions.
I'll leave that to the doctor.

(You must still pay for your prescription at the pharmacy.) Choose Preferred Prescription Refill Plan. *

The simplest is an internet visit (30-day supply mailed to your pharmacy with one refill). NOTICE: Medication is NOT included; you must pay for your prescription at the pharmacy.
ADVANCED: Online visit (90-day supply sent to your pharmacy without refills). NOTICE: Medication is NOT included; you must pay for your prescription at the pharmacy.
A PREMIUM online visit includes a 90-day supply and one refill supplied to your pharmacy. WARNING: Medication is NOT included; you must still pay for your prescription at the pharmacy.
Online visit (90-day supply mailed to your pharmacy every 90 days until cancelled; medication NOT included; you must still pay for your prescription at the pharmacy) is the quarterly subscription plan's *BEST VALUE.

Financial accountability (paying for prescription drugs) *

I am aware that the cost of the drug is not covered by the telehealth service fee. I understand that unless I've enrolled in a subscription plan with home delivery, I'll still need to pay for my prescriptions at the drugstore.

Do you want to know when we start offering therapy and counseling services? *

Please let me know when this service is available.
No! I have a therapist
I have no interest

Leave a comment or feedback (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 *

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Consultation Fee

Price: $34.99

Stripe Credit Card *