Telehealth Survey COVID Treatment with Symptoms (HYDROXYCHLOROQUINE & IVERMECTIN)

First time visit

Complete all 10 steps below — your information is submitted securely.

Step 1 of 10 Personal Details

Please fill out your personal details.

First Name *

Middle Name

Last Name *

DOB *

Gender *

Male Female

Street Address *

City *

Country *

State *

ZIP *

PhoneNo *

Best Time to call you *

Email *

Step 2 of 10 Telemedicine Survey | General

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

What is your chief complaint? *

What is your Height? *

What is your weight? * Example: 190 (numerical only in pounds)

What is your current medical diagnosis? *

What current medications are you taking? *

Are you Diabetic? *

Yes No Not Applicable

Do you take oral or insulin to treat diabetes? *

Oral Insulin Both Not Applicable

Do you have any allergies: *

Are you allergic to any medication? *

Have you seen doctor in last 12 months: *

Yes No

Have you recently experienced a cough or allergy symptoms? Such as runny nose, itchy eyes, or scratchy throat? *

Yes No

Do you experience Seasonal Allergies? *

Yes No

Do you often feel sluggish, lack energy, or get frequent colds or flu? *

Yes No

Do you have chronic heartburn or acid reflux? *

Yes No

Step 3 of 10 Telemedicine Survey | Telemed Acknowledgement

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

By checking this box and requesting an appointment, you will be provided the opportunity to consult with a licensed physician or nurse practitioner that is licensed in your state of residence. This does not guarantee that the requested medications will be prescribed. We rely on the experience and medical knowledge of our highly qualified physicians to provide the best patient care possible through telemedicine. * I Agree *

Step 4 of 10 Telemedicine Survey | COVID-19 - Section One

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

Are you experiencing any of the following symptoms:

Fever or chills or 100F or higher *

Yes No

Cough *

Yes No

Shortness of breath *

Yes No

Fatigue *

Yes No

Muscle or body aches *

Yes No

Headache *

Yes No

New loss of taste or smell *

Yes No

Sore throat *

Yes No

Congestion or running nose *

Yes No

Nausea or vomiting *

Yes No

Diarhea *

Yes No

Pulse rate/O2 stats *

Yes No N/A

Step 5 of 10 Telemedicine Survey | Pharmacy Request

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

Pharmacy Name *

Pharmacy Telephone Number

Pharmacy Fax

Step 6 of 10 Telemedicine Survey | HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient's right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By agreeing to this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By clicking the below check, I understand that: Protected health information may be disclosed and used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon the execution of this consent. * I agree *

Step 7 of 10 Telemedicine Survey | Seasonal Allergies

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

How long have you exhibited symptoms of seasonal allergies? * If no seasonal allergies, put NONE

What symptoms do you experience? * (ex itchy watery eyes, cough, runny nose)

Are you currently taking an anti-histamine? *

Yes No Not Applicable

Would you be interested in a anti-histamine if the physician deems you a good candidate for this treatment option? *

Yes No Not Applicable

Step 8 of 10 Telemedicine Survey | COVID-19 - Section Two

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

Have you been in close contact with a laboratory confirmed COVID-19 case? *

Yes No

Have you been in contact with a person hospitalized with acute lower respiratory illness of unknown origin? *

Yes No

Do you have any history of travel to or from an affected geographic area with widespread community transmission? *

Yes No

Do you have a history of international travel or a cruise? *

Yes No

Are you 65 and or older with a history of chronic health conditions? *

Yes No

Have you been vaccinated against Covid19? *

Yes No

If yes what vaccine did you take?

Moderna Pfizer

How many doses?

First Second More than two

Step 9 of 10 Telemedicine Survey | Flu Screening

Please fill out a short questionnaire to help the Provider determine medical necessity for a medical prescriptions and medical advice.

Are you running a fever of 100F or greater? *

Yes No

Are you experiencing any of these symptoms? *

None Sore Throat Nasal Congestion Runny Nose Extreme Tiredness Body Aches Muscle Aches Vomiting Diarrhea

Have you been experiencing these symptoms for longer than 4 days? *

Yes No Not Applicable

Are you having trouble breathing or shortness of breath? *

Yes No

Are you currently taking any medications to self-treat your symptoms? *

Yes No

Step 10 of 10 Telemedicine Survey | Hydroxychloroquine Consent form

The above name medication is approved for use in the United States to treat other diseases. They have been anecdotal reports of its efficacy in covid19 patients worldwide. They are still clinical trials going on to prove efficacy and toxicity.

I am aware that my doctor can prescribe it off label.

In rare cases the medication can cause arrhythmia or irregular heart beat.

I have been informed of these facts and I agree with Dr. Stella Immanuel and other providers in her organization to give me this medication to treat covid19 and related symptoms or for prophylaxis.

Hydroxychloroquine * I agree *

I consent to the above treatment and I want to release Rehoboth Medical Center from any medical liability from such treatment. * I agree *

Ivermectin should not be taken with Warfarin /Coumadin because it may increase risk of bleeding. You can ask you doctor to change your blood thinner. I am not on Warfarin/Coumadin. Agree? * I agree *