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General Patient Form
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Name
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First
Last
Email
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Phone
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How Did You Hear About Us?
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Recommendation / Referral
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Other
Are you new patient or existing patient?
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New Patient
Existing Patient
Do you have a medical emergency or something that requires quick medical attention?
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Yes
No
If you are able to safely do so, proceed to the nearest emergency room; otherwise, contact an ambulance. We can't safely assess and treat emergencies via the internet, and we can't promise any immediate medical examinations.
*
I Understand
Are you looking for help right now with any of these SERIOUS or DANGEROUS issues?
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I DO NOT HAVE ANY OF THE FOLLOWING.
I HAVE ONE OR MORE OF THE FOLLOWING SIGNS AND SYMPTOMS: severe difficulty waking up, extreme confusion, recurrent fainting, severe vomiting or diarrhea, coughing up blood, vomiting blood, bloody stool, suicidal thoughts, violent thoughts, can't breathe, severe shortness of breath, can’t swallow food or water, trauma, possible broken bone, worst headache ever, sudden onset headache, any sudden and severe pain, difficulty speaking, slurred speech, suddenly can’t find words, new face drooping, new loss of bowel or bladder control, new loss of ability to move, new loss of sensation, moderate to severe chest or upper stomach pain for more than 2 minutes, very unusual stomach pain, eye pain, change in vision, shingles affecting the eye, unusual or unexplained change or loss of hearing, uncontrolled bleeding, bad burn, facial burn.
If you experience any severe or potentially life-threatening symptoms, you should visit a doctor right once. We are unable to analyze and treat these online in a safe or timely manner.
*
I Understand
Please check all of the symptoms you're experiencing:
*
Unusual Dizziness
Lightheadedness
Difficulty Waking Up
Confusion
Fainting
Severe Vomiting or Diarrhea
Coughing Up Blood
Vomiting Blood
Bloody Stool
Suicidal Thoughts
Violent Thoughts
Can’t Breathe
Moderate to Severe Shortness of Breath
Can’t Swallow Food or Water
Trauma
Possible Broken Bone
Worst Headache Ever
Sudden Onset Headache
Any Sudden or Severe Pain
Difficulty Speaking
Slurred Speech
Suddenly Can’t Find Words
Face Drooping
Loss of Bowel or Bladder Control
Loss of Ability to Move
Loss of Sensation
Chest or Upper Stomach Pain for more than 2 minutes
Unusual Stomach Pain
Eye Pain
Change in Vision
Shingles Affecting the Eye
Unusual or Unexplained Change or Loss of Hearing
Uncontrolled Bleeding
Bad Burn
Facial Burn
You may have a serious ailment that is not appropriate for online screening based on the symptoms you picked. You might need to go to an urgent care center or the emergency room. By continuing with your visit, you agree to hold us harmless if we make a mistake in diagnosing your disease owing to the inherent limits of telemedicine.
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I Agree
Which state are you in now?
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If your state is not listed above, it means that we are not licensed to prescribe in that state yet. Please stay tuned as we are working on getting more license soon!
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Select A Condition or Service to Start:
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Psychiatric Condition
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Common Medical Conditions
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Specify Your Condition
Psychiatric Condition
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Attention Deficit Hyperactivity Disorder (ADHD)
Bipolar Disorder
General Anxiety Disorder
Depression
Insomia
Mental Health Medication
Men's And Women's Health / Sexual Health
*
Genital Herpes
Trichomonas
Chlamydia
Gonorrhea
Vaginal Yeast Infection
Bacterial Vaginosis
Period Delay
Birth Control
Erectile Dysfunction (ED)
Premature Ejaculation
Hair Loss
Other STD & Exposure Treatment
Common Medical Condition
*
Urinary Tract Infection (UTI)
Hypertension / High Blood Pressure
Sinus Infection
Bronchitis / Upper Respiratory Infection (URI)
Acne / Skin Problem
Urethritis
Dental Infection
Strep Throat
Cold Sore
Allergies
Flu Infection
Covid-19
Other Medical Conditions
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Pain Management
Opioid Treatment
Weight Loss
Quit Smoking
Addiction Treatment
Medication Refill & Adjustment
Other Services
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Medication Refill
Sick / Work Note
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Identification Card
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Please upload a picture of your ID (front & back)
Selfie Upload
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Allergies
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Preferred Pharmacy
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Do you have previous lab results or previous prescription?
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Lab Results | Prescriptions
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You can upload up to 5 files.
Please upload your most recent lab results or prescription.
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