Motion Sickness Consultation

Motion Sickness Consultation

Appointment Required. We do not bill insurance for this consultation.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Patient Gender*

MaleFemale
Are you pregnant and/or breastfeeding?*

YesNo
Race*
Ethnicity*
Mobile Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name (if applicable)

First NameLast Name
Consent for Services

Before providing your consent, be sure that you understand both the pros and cons of receiving treatment from a pharmacy provider. If you have any questions, we will be happy to discuss them with you. Do not sign your name on this form until you have read and understood each statement and the pharmacist has answered any questions that you may have. This information is confidential.

- I understand the benefits and risks of receiving treatment.
- I have voluntarily chosen to receive care service from a pharmacy provider.
- I understand that Pharmacists can assess and treat some authorized conditions, and administer certain services including diagnostic testing, and vaccinations.
- I voluntarily assume full responsibility for any reactions or consequences that may result.
- In the event of side effects, I understand I should call the pharmacy, my doctor, or 911.
- I have had the opportunity to ask any questions I might have about the care and services provided to me by a pharmacy provider and the alternatives prior to my informed consent. I give consent to receive care services from the pharmacy provider, including any medications recommended or prescribed, or instructions from the pharmacy provider.
- I understand if the pharmacy provider cannot provide effective care, I may be referred to an appropriate care provider.
- I have read or have had read to me all of the above statements and understand them.
Authorization to Request Treatment

I am requesting participation in receiving treatment for the pharmacist prescribed Motion Sickness program. I certify that the information provided regarding eligibility for the treatment is accurate and request that the treatment be given to me or to the person previously named for whom I am authorized to make this request. If I am signing on behalf of another individual (including a minor), I attest that I have the authority to do so.

I authorize the pharmacy providing services to release information to Medicare, Medicaid, or any other third party payer as needed and to request payment of authorized benefits to be made on my behalf to the pharmacy providing services, I certify that the information provided about my Medicare, Medicaid or other coverage is correct.
Disclosure of Records

I understand that the pharmacy providing services may be required to or may voluntarily disclose my health information with respect to this treatment to my healthcare providers, my insurance plan, health systems, hospitals, and/or state or federal registries. I understand that the pharmacy providing services will use and disclose my health information as set forth in the pharmacy privacy policy (a copy is available by request from the pharmacy team).
I have read, and understand the above statements*

Yes
Motion Sickness Patient Assessment

Before collecting any more health information, we want to emphasize that not all of our patients will be eligible for a prescription for Motion Sickness, but all patients will still be responsible for paying any applicable consultation fee.

Patient may be eligible if:

- Previous diagnosis of motion sickness
- Age between 2 and 65
- No allergy to meclizine, scopolamine, promethazine, or dimenhydrinate

Patient may not be eligible if:

- New-onset motion sickness/no previous diagnosis of motion sickness
- Neurological symptoms such as ringing in the ears, hearing loss, numbness/tingling, severe headaches/migraines,
- Lethargy, confusion, trouble swallowing, numbness/tingling, muscle weakness, or neck stiffness are present with dizziness
- Age < 2, Age >/= 65
- Persistent Vomiting (More than 3 episodes in 12 hours)
- Pregnancy or breastfeeding
- Signs of infection (fever, chills, body aches, etc)
- Abdominal pain, new-onset diarrhea, or constipation

If you choose to continue you will be asked to complete a self-assessment with questions that will be reviewed with you by a pharmacist during your consultation at the pharmacy. The pharmacist will refer to your responses to help make a safe, informed decision about appropriate care.
I have read, and understand the above statement*

Yes
Have you been diagnosed with motion sickness in the past?*

YesNo
Are you currently experiencing motion sickness?*

YesNo
What symptoms do you have with your episodes? (Select all that apply)*

NauseaDizzinessUnsteady gaitVertigoVomitingHyperventilationStomach awarenessDrowsinessIrritabilityNone of the above
Have you tried any medications for motion sickness in the past? (Select all that apply)*

MeclizineDiphenhydramine (Benadryl)Dramamine (Dimenhydrinate)PromethazineScopolamine PatchOther
Are you pregnant, think you may be pregnant, or are trying to become pregnant?*

YesNoUnsure
Some conditions may change what we are able to prescribe for you. Do you have any of the following? (Select all that apply)*

Paralytic ileusPyloric obstructionAbnormal heart beatsHyperthyroidismMyasthenia gravisBenign prostate hyperplasia (BPH)Urinary obstruction or a catheterUrinary retentionPsychosisSeizure disorderKidney DisorderAsthmaGlaucomaNone of the above
Please list any other medications or supplements you take. This includes herbs and over-the-counter products*
Please list any other allergies or drug allergies. *
Type none if no allergies
Is there anything else you would like your pharmacist to know?
Appointment*
By signing below I agree to pay all applicable charges for the motion sickness consultation and any medications that I choose to receive. I understand that if I cancel less than 24 hours prior to the appointment time I will not be refunded.
I have read, and understand the above statements*

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