UTI – 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

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
None

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 Applicable Surgical History *

No surgical history
Orthopedic surgery
Hernia repair
Breast augmentation
Tonsillectomy
Hysterectomy
C-section
Appendectomy
Gallbladder surgery
Mastectomy

Do you breastfeed or nurse? *

Breastfeeding Precaution *

I am aware that oral drugs used while nursing may pass into the baby's milk. Only medicines without a prior history of negative side effects will be prescribed by us. In general, you should think about pumping and discarding breast milk while taking certain medications and an additional two days after last dose if you can't stop breastfeeding during therapy.

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

The cause of getting UTI treatment *

I have signs of a UTI
Positive urine test results done at home
Positive urine lab test

How frequently do you get UTIs? *

This is my debut episode
Once in a while
Occasional
Often
Frequently (Chronic)

Do you have any of these risk factors of UTI? *

Holding Your Pee
Wiping from back to front(Women)
Uncontrollable bladder
Anal sex without protection
Kidney Stones
Prostate disease or BPH
Weakened immunity
Use of a Diaphragm or Spermicides
Nephrostomy tube, stent, or indwelling catheter
None of the above risk factors

Which of these symptoms do you currently have? *

Burning urination (Dysuria)
Constantly urinating
Strong urge to urinate
Little ache in the flank (back)
Lower abdomen discomfort
Urethral blood
Abdominal pain

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 the following best sums up your blood pressure? *

Regulated (less than 140/90)
(Over 140/90) Uncontrolled blood pressure

When did your symptoms first appear? *

Less than 7 days
Started 7 to 14 days ago
Symptoms have persisted for the past four weeks
For the past month, symptoms has been inconsistent
Symptoms began more than a month ago

Do you have any of these genital discharge? *

No discharge
Normal discharge
Dense, white discharge
Yellow to green discharge
Stench-filled discharge
Foul vaginal odor

If any, briefly describe any additional symptoms you may be experiencing.

When did you last experience UTI? *

It's my debut episode.
In the last one month
Within the last 1 to 3 months
3 months ago
Over 6 months ago

Are you currently taking any medication for UTI ? *

Name of medications *

Have you received any medical care for UTI in the last six months? *

Which of these drugs would you want to be prescribed for UTI? *

Nitrofurantoin (Macrobid)
Cefuroxime
Cephalexin (Keflex)
Amoxicillin-clavulanate (Augmentin)
Bactrim (trimethoprim-sulfamethoxazole)
Ciprofloxacin. (Last option due to their serious side effect profile)
I'll let the doctor decide

Do you require additional medication for a yeast infection or burning urination? *

Phenazopyridine HCl 200 MG
Fluconazole for yeast infection
Fluconazole for yeast infection
No additional Rx needed

Follow-up agreement *

I agree to follow up with a doctor if my symptoms persist or go to the ER immediately if my condition worsen

Important Disclosure: I pay for prescription drugs *

I am aware that the cost of the drug at my pharmacy must still be paid.

Would you wish to send the medical provider any pictures of yourself or supporting documents? *

Place pictures and medical records online

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

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 my 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: $34.99

Stripe Credit Card *