Upper Respiratory

Date*

MonthDayYear
Current Location:*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Age*
Phone Number*
Please enter a valid phone number.
What is your birth-assigned gender?*

FemaleMale
Height (inches)*
Weight (lbs)*
Email*

Confirmation Emailexample@example.com
Address*
Legal Guardian's Name*

First NameLast Name
I attest that I am the legal guardian and consent to treatment of the minor listed above. *

Clear

Terms of Service
I am not covered by Medicare or MedicaidI am covered by Medicare or Medicaid and I agree to the terms of the Advanced Beneficiary Notice (ABN)
Advance Beneficiary Notice

Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor.

You should not use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:
- Severe of unusual chest pain
- Severe shortness of breath
- Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
- Thoughts of harming yourself or others
Are you experiencing an emergency? If you are experiencing an emergency, call 911 or go to an emergency room immediately*

Yes, I am having an emergencyNo, I am not having an emergency

Are you currently taking any medications?*

YesNo
List your current medications and dose below (ex: Lexapro 10mg once per day)*
Medication Allergies
Do you have any allergies to prescription or over-the-counter medications?*

YesNo known drug allergies (NKDA)
List your medication allergies below:*

Before ending the interview, is there any additional information you would like to share about the following?
- Symptoms
- Recent changes in health
- Medications or any other related health conditions
- Any other relevant information about this visit
Would you like to share additional information?*

YesNo
Please enter the additional information below:
PHARMACY INFORMATION

Please enter the pharmacy name and address where you would like your prescription sent.
Pharmacy Name: *
Pharmacy Address*

Acute Telemedicine Visit

$39.00

Enter coupon

Total

$0.00

Terms of Service