Careborne Sensible Medical

REGISTRATION
Reasons for visit*

New medication prescriptionMedication refillLaboratory or diagnostic testMedical letter/excuse/clearanceSpecialty referralForms filled outOther
Any other issues/requests?
Current location*

New YorkFloridaArizonaOther
Name*

First NameMiddle NameLast Name
Date of birth*

MonthDayYear
Sex:*

MFOther
Weight in pounds if child
Height in inches if child
Cell phone number*

Area CodePhone Number
Email*
example@example.com
Current address*

Street Address

CityState

Zip Code
Preferred pharmacy (name, address, phone number)*
Primary care provider (name, address, phone #) if known
MEDICAL HISTORY

Health screening

	No	Yes
Are you pregnant or breastfeeding?
Are you on blood-thinning medications?
Are you taking any pain medications?
Are you on dialysis?
Have you taken an antibiotic in the past month?
Have you been to a doctor/ER recently?

Are you currently on any medications?*

YesNo
Current medications (name, dose, effectiveness)
Are you allergic to any medications?*

YesNo
Allergies to medications (name, reaction)
Chronic medical issues (medical history)*

AnemiaArthritisAutoimmune disease, cancer, HIVChronic painDiabetesFrequent sinus infection, allergiesHeart disease, procedureHigh blood pressureKidney diseaseLiver diseaseLung problems, asthma, COPDMental health issues/medicationsProstate issuesThyroid problemsUrinary issues, infectionNoneOther
MEDICAL ISSUE / REQUEST
Please describe your current medical issue/situation in detail*
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HOW ARE YOU FEELING NOW?
General

Tired, sleepyRecent weight loss or gainAlways hot or coldNight sweatsOther
Head, Eyes

HeadacheDizzinessRecent head traumaFacial pain, swellingPoor vision, spotsEye problemOther
Ear, Nose, Mouth, Throat

Hearing lossEar pain, dischargeRinging in earsNasal obstruction, congestionNosebleedsMouth soresDental or jaw problemsHoarsenessInflamed neck glandsSore throatOther
Breathing, Lungs

Cough, phlegmShortness of breathWheezingPain with breathingOther
Heart, Circulation

Chest pain with activityLosing breath, shortness of breathSkipped heart beats, palpitationsAnkle/feet swellingOther
Stomach, Digestion

PainHeartburn, acid refluxPoor appetite, get full quicklyConstipation or diarrheaBlood in stool, black stoolNausea, vomitingRectal bleeding, hemorrhoidsOther
Kidney, Urinary

Blood in urineFrequency, urgency, burningUrine loss with coughingOther
Men's Health

Weak stream, strainingWaking up at night to urinateWeak erectionsTesticular pain, swelling, nodulePenile discharge, sores, wartsOther
Women's Health

Vaginal discharge, bleedingMissed periodsOther
Blood, Immune System

AnemiaLymph node swellingBruise easilyOn anticoagulant or antiplatelet drugsOther
Musculoskeletal

Neck, back painJoint pain, swellingExtremity, muscle painOther
Nervous System

Dizziness, faintingEpilepsy, seizuresAnxiety, depression, stressPoor sleepThoughts of self-harmMood swings, irritabilityTingling, numbnessTremorsOther
Skin

Rashes, wounds, soresEczema, drynessSwelling, infectionHair lossNail problemsOther
CONDITIONS OF SERVICE

Services
Careborne Sensible Medical (“CAREBORNE” or “WE/OUR/US”) offers evaluation and treatment of routine non-life-threatening illnesses ("SERVICE"). If you are experiencing a medical or psychiatric emergency, please contact your local emergency medical services (911) immediately.

Self-Payment

You are fully responsible for all charges regardless of the health coverage you may have. CAREBORNE neither bills nor processes commercial insurance, Medicare, Medicaid, or any other third-party coverage.

Medication Prescription

Medications are prescribed when deemed appropriate. CAREBORNE does not prescribe medications that fall outside of OUR expertise, “on request,” or for performance enhancement. Prescriptions are processed in batches, in the afternoon daily.

If CAREBORNE chooses to prescribe medication, WE will promtply notify you. If you decide to claim the prescription, please choose the level of service and pay the Consultation Fee. If you decide to forgo the prescription, YOU OWE US NOTHING.

Changes and Refills

Once you have made the payment, CAREBORNE will send a prescription electronically to the pharmacy of your choice. WE cannot change or edit any incorrect information on the prescription or send a new prescription to a different pharmacy. Please choose your pharmacy carefully taking into consideration their operating hours, location, and prices. Also, keep in mind that the Consultation Fee covers only the current prescription(s). It does NOT cover any future medication refills/changes or follow-up care. If you need a change or refill, another appointment will be required.

Payment

By accepting the prescription(s), you are authorizing CAREBORNE to charge the one-time non-refundable Consultation Fee and agreeing not to dispute this charge so long as the prescription has been sent to the pharmacy of your choice.

No Refunds

Healing is an inherently unpredictable and inexact process: your condition may take time to resolve or, in some rare cases, even fail to improve. CAREBORNE will provide no refunds or credits regardless of the treatment results.

Future Services

CAREBORNE will not assume responsibility for your primary care or guarantee any future services or medication refills. You are expected to inform your regular (primary care) doctor about changes in your health.

Privacy

The Notice of Privacy Practice (NPP) is displayed on OUR website. NPP provides information about OUR use of your protected health information (PHI) and your rights under the law to access, inspect, and copy PHI.

Medical Records

All forms of electronic communication, including phone calls, telemedicine consultation, texts, and emails, may be recorded and included in your medical record.

Unencrypted Electronic Communication

You agree to communicate with CAREBORNE electronically through unencrypted (unsecure) means, such as regular email and text (SMS). Any communication sent to the email address and phone number you have provided during registration will be effective once delivered, regardless of whether or not you choose to open/read it.
TREATMENT CONSENT

I AGREE TO PROVIDE THE ACCURATE AND UPDATED INFORMATION REGARDING MY IDENTITY, LOCATION, HEALTH CONDITION, PAST ILLNESSES, POSSIBLE PREGNANCY, PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS TAKEN, ALLERGIES TO MEDICATIONS, AND OTHER MATTERS THAT MAY AFFECT DIAGNOSIS AND TREATMENT. I PERMIT CAREBORNE TO VERIFY MY PRESCRIPTION HISTORY WITH PHARMACIES, INSURANCE PLANS, AND STATE PRESCRIPTION DRUG MONITORING PROGRAMS.

I CONSENT TO EVALUATION, DIAGNOSTIC PROCEDURES, TESTING, AND TREATMENT AS DIRECTED BY PROVIDER.

VIRTUAL APPOINTMENTS: I AGREE TO ASSUME FULL RESPONSIBILITY FOR ALL RISKS AND LIMITATIONS ASSOCIATED WITH A VIRTUAL TELEMEDICINE VISIT. SINCE CAREBORNE IS UNABLE TO PHYSICALLY EXAMINE ME AND INDEPENDENTLY VERIFY THE INFORMATION AND/OR IMAGES PROVIDED, THERE EXISTS A CHANCE THAT I MAY RECEIVE AN INACURATE DIAGNOSIS AND/OR TREATMENT. IF MY CONDITION FAILS TO IMPROVE OR WORSENS, I MUST CONTACT MY PCP OR ANOTHER LOCAL HEALTH CARE PROVIDER FOR IN-PERSON CONSULTATION. IF I AM UNABLE TO REACH MY REGULAR HEALTH CARE PROVIDER (PCP), I WILL SEEK EMERGENCY CARE IMMEDIATELY BY CALLING 911 AND/OR PROCEEDING THE NEAREST EMERGENCY ROOM.

I AGREE THAT MY ELECTRONIC SIGNATURE IS THE LEGAL EQUIVALENT OF MY MANUAL SIGNATURE AND THAT NO CERTIFICATION AUTHORITY OR OTHER THIRD-PARTY VERIFICATION IS NECESSARY TO VALIDATE MY E-SIGNATURE.
BY CLICKING THE “REGISTER AND PAY” BUTTON, I AGREE TO TERMS OF SERVICE, GIVE MY TREATMENT CONSENT, AND AUTHORIZE THE NON-REFUNDABLE PAYMENT.
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REGISTRATION

CONDITIONS OF SERVICE