Important Next Step to Meet your Wyndly Doctor
Welcome to Wyndly! Before our doctors can create your treatment plan we need essential patient information.
Patient and Contact Information
The patient is the person who will be receiving treatment. The contact is who Wyndly should contact for scheduling and billing. For most people, this is the same person. For parents and minor children, the parent is the contact and the child is the patient. The patient must be present during the doctor consultation.
Patient's Full Name
*
First Name
Last Name
Patient Date Of Birth
*
-
Month
-
Day
Year
Date
Patient's Sex at Birth
*
Male
Female
Patient's Sex at Birth
*
*Required for a medical history and charting only.
Contact Email
*
Contact Phone Number
*
Format: (000) 000-0000.
Patient's Permanent Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you ever been tested for environmental allergies before?
Yes, but I am interested in getting a new test.
Yes, and my doctor has provided my results to Wyndly.
Yes, and I can share my test results.
No, I have never been tested for allergies before.
Upload your allergy test results here.
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If you are prescribed sublingual immunotherapy, Wyndly will ship your medicine directly to your doorstep. Your doctor may also write you a prescription for other medication. In that instance, what is your preferred pharmacy?
Amazon Pharmacy (cheapest generics and home delivery available)
Capsule Pharmacy
Alto Pharmacy
Optum RX
Express Scripts
Caremark (CVS Mailorder)
Local Retail Pharmacy
Pharmacy Name
*
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you selected to send prescriptions to your local retail pharmacy, please provide the name and location of your pharmacy.
What almost stopped you from buying today?
What was going on in your life that made you finally decide to cure your allergies?
How did you hear about Wyndly?
Google Search
ChatGPT / Claude / Gemini AI Chat
YouTube or Tiktok
Instagram or Facebook
LinkedIn or Twitter
Referral from someone I know
Referral from someone I follow
Other
Patient/Guardian Signature
*
Shopify Order ID
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