Followup Mat Funk

Please do not use a private browser or incognito mode as they disable functions that our medical form and checkout page require.

Terms and Notices* This field is required.

Name* This field is required.Please enter your legal name as shown on your driver license.

First Name

Last Name

Email* This field is required.

example@example.com

Are you filling this form out for a patient under the age of 18?Answer "No" if you are 18 or above.

YESNO

What is your relationship to the patient?

Parent/GuardianOther

All of the following questions from here on out regard the patient. So for example, in the next field enter the patient's date of birth.

1. When prompted for the face photo, please provide the a photo of the patient's face.

2. When prompted for a photo of the driver's license, please provide the parent/guardian's drivers license.

What is your birthdate?To change the year on a mobile device, click on the year in the calendar.

Date

Which state do you live in?Please select your state.

What is your biological sex?

Male

Female

Are you pregnant, breastfeeding, or planning on becoming pregnantOur medications CANNOT be used during pregnancy.

YESNO

What were you diagnosed with?

Which areas WERE affected?

Scalp

Face/Neck

Chest/Abdomen

Back

Arms

Armpit/Groin

Legs

Which areas ARE CURRENTLY affected?

Scalp

Face/Neck

Chest/Abdomen

Back

Arms

Armpit/Groin

Legs

Does the rash involve your eye, or near the eye?

YESNO

Are you experiencing any of the following?

None

Fevers, chills, or nightsweats

Joint Aches

Severe Fatigue

Vision Changes

Swollen Lymph Nodes

Do any of these apply?

None

Liver Issues

Heart Issues

Psychiatric Medication Usage

History of Fainting

Family History of Sudden Death

Is your condition improving?

YESNO

Choose one.

Worsened

Slightly Improved

Improved

Significantly Improved

Resolved

For how many days have you been using the prescribed treatment?

1-3 days

4-14 days

Longer than 2 weeks

I have not used it

Has it been spreading since starting treatment?

Not spreading

Spreading

Tell us about the itch.

0 No itch

Itch has improved.

Still itchy.

Itch has worsened.

In the last 3 days have there been any new lesions (rashes)?

Yes

How would you rate the Pain from 0 to 5?

0 - No Pain

1 - Mildly tender when touched

2 - Painful when touched

3 - Mildly painful without touching

4 - Moderately painful without touching

5 - Extremely painful

Has the pain improved since starting treatment?

YESNO

Which of the following apply?

Red

Scaly (flaky)

Hypopigmented (lighter color)

Hyperpigmented (darker)

Are any of these present?

Pustule (White Heads)

Papule (Bump)

Nodule (Deep Big Bump)

None

Are any of these present?

Skin colored bumps

Pink colored bumps

Raised pink/red patches

None

Are any of these present?

Grouped yellow pustules

Grouped small blisters

Blister >4mm

None

Are any of these present?

Yellow scab

Yellow crust

None

Which of the following apply?

Not Oozing

Oozing - Clear Fluid

Oozing - White Pus

Oozing - Yellow Fluid

Oozing - Red Fluid

Oozing - Green Fluid

Are any of these present?

Ring

White Patches

Dark Patches

None

Is the ring scaly? Or Not scaly?

Scaly (Flaking)

Not Scaly (No flaking)

Are any of these present?

Rough red patch

Patch on scalp

Thick scale on scalp

None

Are any of these present?

Scaly palms

Peeling between toes

Scaly red feed

Discolored nails

None

Are any of these present?

Elbow involvement

Knee involvement

Eyebrow involvement

None

In the next section upload a clear picture of your face, and provide a photo of your government-issued ID to comply with telehealth laws.

How would you like to upload your photos?If multiple photos are required to show the entire rash, choose Upload and select multiple photos.

Use CameraUpload

Photo of Affected Area(s) - From Arm LengthCamera not compatible with private browsers, pop-up blockers, and VPN.

Photo of Affected Area(s) - Close Up and FocusedCamera not compatible with private browsers, pop-up blockers, and VPN.

Photo of Affected Area - From Arm Length

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo of Affected Area - Close Up and Focused

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

In the next section upload a clear picture of your face, and provide a photo of your government-issued ID to comply with telehealth laws.

Provide a picture of your face. Please ensure that:

1. Your face is well lit and clear

2. Your entire face is visible

3. You're the only person in the photo

4. Nothing is covering your face

Upload photo of face

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Identity Verification. Please ensure that:

1. ID card is a valid driver license or passport

2. Photo is clear, and all edges are showing

3. Full name and DOB are visible

Upload driver license or passport

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

Photo of driver license or passportIf your camera is not working, please try in a private window or use the Chrome browser.

Provide a picture of MINOR's face. Please ensure that:

1. Your face is well lit and clear

2. Your entire face is visible

3. You're the only person in the photo

4. Nothing is covering your face

Is there anything you want your provider to know about the rash? For example: how it has been since starting treatment, etc.If none, move onto next question.

Please list any medications, vitamins, and supplements you are taking.If none, move onto next question.

Please list any allergies.If none, move onto next question.

Please list any medical conditions you have been diagnosed with, and any surgeries you have had.If none, move onto next question.

Pregnancy Attestation

Based on your answers you should be seen in person by a medical provider.

Based on the answers you provided we cannot prescribe you anti-aging treatment through our online platform.

It is recommended that you follow-up with your primary care physician, or a dermatologist.

Currently our telemedicine platform not operating in your state. However, we are planning to launch to your state by the end of the year!

We will send you a notification as soon as we're in your area!

My Bag

Medical VisitThis includes the cost of your virtual consultation.
$49.00Edit
Back

Click submit and start treatment today!

*Prescriptions are not guaranteed, and are only issued after a provider determines that the prescription is medically indicated. We can either arrange for your prescription to be delivered to you, or provide you with the written prescription. If the medical provider determines that you are not a candidate for therapy, then you will be refunded!