Gerd (Acid Flux) – Reddydoc

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First Name *

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Date of Birth *

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Gender *

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Who is the patient? *

What disease are you suffering from? *

Select Your Location *

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Consent to use information *

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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

Other Condition

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

Have you been evaluated for Acid Reflux (GERD) by a medical provider? *

Yes
No! I have NOT seen a doctor for GERD

Please explain the encounter and the recommended treatment plan

Have you been treated for Acid Reflux (GERD) including over the counter drugs? *

Yes
I have NOT been treated for Acid Reflux (GERD)

Enter the medication used and treatment outcome *

Which of these tests have you undergone? *

Endoscopy
H-pylori test
Barium swallow test
X-rays of your upper GI tract
Esophageal manometry
Ambulatory acid (pH) probe test
None of the above diagnostic tests

If applicable, explain the test result

Which of these Acid Reflux (GERD) symptoms do you experience? *

Burning sensation in your chest (heartburn)
Indigestion
Backwash (regurgitation) of food or liquid
Trouble swallowing (dysphagia)
Sore throat and hoarseness
Upper abdominal pain
Sensation of a lump in your throat
Nausea
Cough
Other

Other symptoms

Describe your symptoms or provide additional information about your condition *

When did you start experiencing these symptoms? Select the closest timeline *

Less than one week
Longer than one week
Longer than 1 month
Longer than 3 months

How often do you experience these symptoms? *

This is my first episode
Occasionally or intermittently
Frequently
Daily

Severity of your Acid Reflux (GERD) symptoms *

Mild symptoms
Severe symptoms
Moderate symptoms

Which of these causes or risk factors of Acid Reflux (GERD) is applicable to you?

Smoker
Overweight or obese
Eating large meals or eating late at night
Eating certain foods (triggers) such as dairy, spicy, fatty or fried foods Medicines for asthma, high blood pressure, allergies, painkillers, sedatives and anti-depressants
Drinking beverages, such as alcohol or coffee
I have a connective tissue disorder
Pregnancy
Hiatal hernia
Other

Other factors applicable

Briefly explain the cause of your symptoms *

Do you have any of these other conditions? *

Chest Pain
Uncontrollable vomitting
Bloody stool
Anemia
Unexplained weight loss
Gastrointestinal cancer in a first-degree relative
Persistent Wheezing
None of these conditions

STOP! You've selected a severe symptom. Send us an email to provider@www.condition.reddydoc.com for further assistance

Nature of chest pain *

Heartburn (Burning pain located in the middle of the chest)
Chest pain with difficulty breathing
Chest pain radiating to left side
Heaviness on my chest
Cardiac pain (feels like a heart attack)

STOP! You may be experiencing a heart attack. Please call 911 immediately

Do you have any of these symptoms? *

Feeling dizzy with sensation of passing out
Vomiting blood
I have a fever
None of these symptoms

You're not a candidate for treatment. See your doctor

Which of these medications would you like us to prescribe *

Pantoprazole (Protonix)
Cimetidine (Tagamet)
Famotidine (prescription strength)
Esomeprazole (prescription strength)
Sucralfate (for stomach ulcer)
Omeprazole (prescription strength)
Dexlansoprazole (Dexilant)
I'll let the doctor decide

Select Preferred Billing Method *

($1.00)One-time Visit (30 days supply Only)
($1.50)One-time Visit (90 days supply Only)
($1.20)Subscribe & Save (Billed Quarterly)

Important Information: We do not include the cost of medications in the consultation price. *

I am aware that even if my insurance does not cover a particular prescription, I will still need to pay for it at my local pharmacy.
I understand that the consultation fee is non-refundable after the medical provider has transmitted the medication to my pharmacy

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? *

Leave a comment or feedback (Optional)

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 *