Unsure – Reddydoc

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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

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 operations you have had in the past. *

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 conditions

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
Implanting breasts
C-section
Gallbladder surgery
Hysterectomy
Hernia repair
Mastectomy
Orthopedic surgery
Tonsillectomy
Various surgeries

List any more operations you had in the past. *

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

Are you allergic to Rocephin, Penicillin, Amoxicillin, or any other drug in that group? *

What drug do you have a reaction to? *

Choose the main justification for your visit today. *

I exhibit STD symptoms.
I had intercourse with a partner who had an STD.
I was found to have an STD.

Which of these describes the individual(s) you were exposed to? *

I came into contact with someone or people who had an STD.
I came into contact with someone who has STD symptoms.
My partner has received STD treatment.

Have you engaged in unprotected sexual activity with somebody who has had an STD diagnosed? *

You tested positive for which of these infections. The test outcome is necessary.

Chlamydia
Gonorrhea
Trichomoniasis
Herpes
Mycoplasma
Ureaplasma
Syphilis
UTI
Other

Give more details *

Which one of these illnesses did your companion have a diagnosis for? IMPORTANT *

Chlamydia
Gonorrhea
Both Chlamydia and Gonorrhea
Trichomoniasis
Mycoplasma
Unreaplasma
Herpes
Syphilis
Other

Other Illnesses *

How did you get an STD? *

oral sex
Vagina Intercourse
Rectal intercourse
Non-sexual exposure to bodily fluid
None of the above

Do you have an unusual discharge? *

Select the type of discharge *

Clear (abnormal) discharge
Mucus
Yellow to green discharge
Rectal discharge

Do you experience any of these signs? *

Testicular swelling
Testicular pain
Dried secretions on the tip of the penis
Pain and redness at the opening (tip) of the penis
None of the above

Do any of these STD signs apply to you? *

Bumps
Painful blister (common in herpes)
Ulcer or sore
Itching and Irritation
Fleshy growth
The absence of certain signs

Give a description of the sore or ulcer, including its location on your body. *

Where is the main location of your symptom? *

The penis
Urethra -Opening (tip) of the penis
Scrotum (testicle)
Penis shaft
Rectum (Anus)
Throat
Groin or inner thigh
Pubic area
Lips
Skin
I have no symptoms.
Other

List other symptom *

What part of your body is the ailment predominantly centered on? *

Have you received treatment for an STD within the last three months? *

Which STDs received treatment from you? *

Since your symptoms began, have you had an STD or UTI test? *

Explain the test result *

Do you have a current STD lab test on file? *

The test results will be uploaded.
I can't easily access a copy of the outcome.
I have not undergone an STD or UTI screening.

Upload STD lab result *

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

Do you want to request STD tests in addition to the medication? *

I require care and STD testing.
Only a prescription is required.
I have not undergone an STD or UTI screening.

Examination Disclosure *

I am aware that the danger of misdiagnosis means that Reddydoc.com cannot guarantee a cure if I choose not to order STD testing or upload a recent STD lab result. I consent to returning to the doctor for testing if my symptoms don't go away.

Which of these ailments would you wish to address right now? *

Only common STDs
Herpes
Other

List other ailments *

Post-treatment Cure Test Disclosure *

The significance of lab tests following treatment has been made clear to me. I hereby release Reddydoc from any liability should I neglect to undergo the advised lab tests or follow-up with my doctor after the prescribed course of antibiotics has been finished.

Financial accountability (paying for prescription drugs) *

I am aware that I still have to pay my pharmacist for the prescribed prescription.

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.

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

Pharmacy Name *

Pharmacy Address *

Pharmacy Phone *

Billing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Consultation Fee

Price: $54.99

Stripe Credit Card *