Mat Funk Visit

1
Please have the name and address of the pharmacy you want your medications sent to on hand - you'll be asked for this in the visit.

Please do not use a private browser or incognito mode as they disable functions that our medical form and checkout page require.
2
Terms and Notices* This field is required.
3
Name* This field is required.Please enter your legal name as shown on your driver license.
First Name
Last Name
4
Email* This field is required.
example@example.com
5
Are you filling this form out for a minor under the age of 18?Answer "No if you are 18 or above.
YESNO
6
Patient's Legal Name* This field is required.
First Name
Last Name
7
What is your relationship to the patient?
Parent/GuardianOther
8
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.
9
What is your birthdate? (Patient's birthdate if filling out for a minor)To change the year on a mobile device, click on the year in the calendar.
Date
Month
Day
Year
10
Which state do you live in?Please select your state.
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
11
What is your biological sex?
Male
Female
12
State Calculator
13
Are you pregnant, breastfeeding, or planning on becoming pregnantOur medications CANNOT be used during pregnancy.
YESNO
14
Are you seeking treatment for lice, scabies, warts, or molluscum?
YESNO
15
Which areas are affected?
Scalp
Face/Neck
Chest/Abdomen
Back
Arms
Armpit/Groin
Legs
16
Are you experiencing hair loss in the area of the rash?
YESNO
17
Does the rash involve your eye, or near the eye?
YESNO
18
Are you experiencing any of the following?
None
Fever
Chills/Nightsweats
Joint Aches
Severe Fatigue
Facial Paralysis
19
Are you experiencing any of the following?
None
Vision or Hearing Changes
Eye Irritation or Photosensitivity
Confusion
20
Is treatment of this rash related to participation in a mat-based activity? (ie. wresting, jiu-jitsu, gymnastics, etc.)
YESNO
21
Did your coach recommend you have your rash checked out?
YESNO
22
What did your coach say your rash might be?
23
Is this your first time experiencing this rash?
YESNO
24
What were you treated for (diagnosis), and what were you treated with (medication)?
25
Do you have kidney issues?
YESNO
26
How long has the rash been present?
1-3 Days
4-14 Days
2-6 Weeks
Longer than 6 Weeks
27
Has it been spreading?
Not spreading
Spreading
28
Rate the itch from 0 to 4.
0 No itch
1 - Slightly itchy
2 - Itchy
4 - Very itchy/Keeping me up at night
29
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 painnful without touching
5 - Unbearably painful
30
Which of the following apply?
None
Red
Scaly (flaky)
Hypopigmented (lighter color)
Hyperpigmented (darker)
31
Are any of these present?
Pustule (White Head)
Papule (Bump)
Nodule (Deep Big Bump)
None
32
Are any of these present?
Skin colored bumps
Pink colored bumps
Raised pink/red patches
None
33
Are any of these present?
Grouped yellow pustules
Grouped small blisters
Blister >4mm
None
34
Are any of these present?
Yellow scab
Yellow crust
None
35
Which of the following apply?
None
Oozing - Clear Fluid
Oozing - White Pus
Oozing - Red Fluid
Oozing - Yellow Fluid
Oozing - Green Fluid
36
Are any of these present?
Ring
White Patches
Dark Patches
None
37
Is the ring scaly? Or Not scaly?
Scaly (Flaking)
Not Scaly (No flaking)
38
Are any of these present?
Rough red patch
Patch on scalp
Thick scale on scalp
None
39
Are any of these present?
Scaly palms
Peeling between toes
Scaly red feed
Discolored nails
None
40
Are any of these present?
Elbow involvement
Knee involvement
Eyebrow involvement
None
41
In the next section upload clear photos of the affected area(s).

Please ensure the photo is clear, IN FOCUS, and high quality with good lighting.
42
How would you like to upload your photos?If multiple photos are needed to show the rash, please select upload and upload multiple.
Use CameraUpload
43
Photo of Affected Area(s) - From Arm Length Camera not compatible with private browsers, pop-up blockers, and VPN.
44
Photo of Affected Area(s) - Close Up and FocusedCamera not compatible with private browsers, pop-up blockers, and VPN.
45
Photo of Affected Area(s) - From Arm Length
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
46
Photo of Affected Area(s) - Close Up and Focused
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
47
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.

Your assigned provider is based on your state of residence. Click here to see your assigned provider.
48
Provide a picture of your face (patient's face if under 18). 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
49
Upload photo of face
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
50
Photo of face
51
Identity Verification (guardian's ID if under 18). 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
52
Upload driver license or passport
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
53
Photo of driver license or passportIf your camera is not working, please try in a private window or use the Chrome browser.
54
Have you been treating this rash at home? If so, with what and for how long?If none, move onto next question.
Huge
Large
Normal
Small
Ok
Ok
55
Have you been previously treated for a similar rash? If so, what were you treated for (diagnosis) and what were you treated with (medication)?If none, move onto next question.
Huge
Large
Normal
Small
Ok
Ok
56
Please list any medications, vitamins, and supplements you are taking.If none, move onto next question.
Huge
Large
Normal
Small
Ok
Ok
57
Please list any allergies.If none, move onto next question.
Huge
Large
Normal
Small
Ok
Ok
58
Please list any medical conditions you have been diagnosed with, and any surgeries you have had.If none, move onto next question.
Huge
Large
Normal
Small
Ok
Ok
59
What is the name of your pharmacy?We will send your medications here.
60
What is the address of your pharmacy?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
61
Pregnancy Attestation
62
Based on your answers you should be seen in person by a medical provider.
63
Acute Worsening
64
Based on the answers you provided we can't prescribe you treatment through our online platform.

It is recommended that you follow-up with a medical provider in person.
65
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!
66
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ORDER SUMMARY
Total costUSD
Medical VisitThis includes the cost of your virtual consultation.
$79.00Edit
Back
Total cost $0.00
67
Done! Lets get you back on the Mats!

*Prescriptions are not guaranteed, and are only issued after a provider determines that the prescription is medically indicated. If the medical provider determines that you are not a candidate for therapy, then you will be refunded!
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