Telehealth Survey COVID Prevention (HYDROXYCHLOROQUINE OR IVERMECTIN)

First time visit

Complete all 7 steps below — your information is submitted securely.

Step 1 of 7 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 4 of 7 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 5 of 7 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 7 of 7 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 *