Medication Refill Visit
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • What was your gender at birth?*

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or 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.*
  • Which type of medication refill is this for?*
  • Do you have an Elite or Basic Membership?*

  • You will need to complete a 'weight loss' visit instead of the medication refill visit. You can discontinue this visit and select the 'weight loss refill' visit on the website or through your Healthie Portal. You can also access the visit here: Weight Loss Visit

  • Anxiety/Depression Medication Refill

  • What do you take this medication for? (Select ALL that apply)*
  • Have you had suicidal thoughts or thoughts of self harm within the last 2 weeks?*
  • Are you currently in counseling/therapy?*
  • Are you interested in starting counseling/therapy?*

  • Asthma Medication Refill

  • Has a provider previously provided you with an asthma prescription?*

  • An asthma attack is a sudden worsening of usual asthma symptoms. Some of these may include coughing, chest tightness, wheezing, and trouble breathing. 

  • Are you currently experiencing an asthma attack?*

  • Wheezing is a high-pitched sound that comes from the chest while breathing. It is commonly described as a whistling sound, similar to wind blowing through a tunnel.

  • Are you wheezing?*
  • Do you feel feverish?*
  • How often do you have asthma symptoms?*
  • In the past 4 weeks, how much of the time did the asthma keep you from getting as much done at work, school, or home?*
  • During the past 4 weeks, how often have you had shortness of breath?*
  • During the past 4 weeks, how often did the asthma symptoms (wheezing, coughing, shortness of breath, chest tightness, or pain) wake you up at night or earlier than usual in the morning?*
  • During the past 4 weeks, how often have you used a rescue inhaler or nebulizer medication (such as albuterol)?*
  • Please rate you asthma control in the past 4 weeks:*
  • Since the last asthma prescription, have you experienced as asthma attack or have the symptoms worsened?*

  • Blood Pressure Medication Refill

  • We need a recent blood pressure and heart rate reading. Are you able to check your blood pressure and heart rate?*

  • It is essential that a recent and accurate reading of your blood pressure is provided. Blood pressure can be checked for free at most pharmacies.
    After the blood pressure is checked, please come back to this visit and enter the blood pressure below. 

  • A blood pressure reading contains 2 numbers written like a fraction (e.g. 120/80; read as "120 over 80"). The higher number (120) is the "systolic" blood pressure. The lower number (80) is the "diastolic" blood pressure. 
    Please enter your blood pressure taken within the last 2 weeks below:

  • Blood Pressure & Heart Rate

  • Birth Control Medication Refill

  • Please select one of the following:*
  • Please tell us the reason for seeking birth control. (Select ALL that apply)*
  • Did you give birth in the last 6 weeks?*
  • Was your last menstrual period more than a month ago?*
  • Is the late period expected due to you being on birth control pills?*
  • Have you forgotten the birth control at any time during the last four weeks?*
  • Please choose the option that best describes your situation in the last 4 weeks:*
  • Have you been sexually active in the last 4 weeks?*

  • If you have NOT had your period in the past month, we ask that a pregnancy test be taken before being presribed any medications. Home pregnancy tests can be obtained at any pharmacy. 
    After a pregnancy test has been taken, please return to this visit. 

  • What was the result of your pregnancy test?*

  • People with high blood pressure should not take some birth control medications. For this reason, it is important that we have a recent and accurate blood pressure reading. 

  • Has your blood pressure been taken within the last 2 weeks?*

  • It is essential that a recent and accurate reading of your blood pressure is provided. People with high blood pressure are at an incrased risk of complications when on certain birth control medications. Blood pressure can be checked for free at most pharmacies. 
    After the blood pressure is checked, please come back to this visit and enter the blood pressure below. 

  • A blood pressure reading contains 2 numbers written like a fraction (e.g. 120/80; read as "120 over 80"). The higher number (120) is the "systolic" blood pressure. The lower number (80) is the "diastolic" blood pressure. 
    Please enter your blood pressure taken within the last 2 weeks below:

  • BLOOD PRESSURE:

  • People with certain medical conditions are at an increased risk of major side effects when on some types of birth control medications. 

  • Do you have any of the following medical conditions? (Select ALL that apply)*
  • Do you have a history of any of the following? (Select ALL that apply)*

  • The risk of using certain medications with birth control medications may outweight the benefits.

  • Do you currently take any of the following medications? (Select ALL that apply)*

  • EpiPen Medication Refill

  • A severe allergic reaction (anaphylaxis) typically occurs within minutes after exposure to something you are allergic to. Anaphylaxis needs to be treated with an injection of epinephrine (an EpiPen). It can be life0threatening if not treated right away. 

  • Are you currently having an allergic reaction? (e.g., difficulty breathing, throat swelling, hoarseness, hives, vomiting?)*
  • Has a provider previously provided you with an EpiPen prescription?*
  • Please tell us a little more about why you require an EpiPen:*
  • Why are you refilling the EpiPen today?*

  • As a reminder, after each time an EpiPen is used, you should go to the emergency room right away for immediate follow up to monitor for worsening symptoms. 
    Please also follow up with your primary care provider if you needed to use an EpiPen for a reaction. 

  • How many EpiPens do you want with this refill?*

  • Erectile Dysfunction Medication Refill

  • Please tell us the reason for your visit today:*
  • Which of the following do you take?*
  • Has your medication been effective?*

  • Since the medication has NOT been effective or side effects were experienced, we are going to ask additional questions about your history of erectile dysfunction.

  • When did your erectile dysfunction symptoms start?*
  • How did symptoms being?*
  • When do you experience erections? (Select ALL that apply)*

  • Premature ejaculation is when ejaculation happens within a short time of entering a partner. 

  • Do you have premature ejaculation?*

  • To better understand the severity of the symptoms being experienced, we are going to ask 5 questions from a commonly used guidelines for the evaluation of erectilye dysfunction. 

    Over the past 6 months:

  • 1. Please rate your confidence of getting and keeping an erection:*
  • 2. For erections caused by sexual stimulation, how often were they hard enough to enter a partner?*
  • 3. During sexual intercourse, how often were you able to maintain an erection after entering a partner?*
  • 4. During sexual intercourse, how difficult was it to maintain an erection to completion of intercourse?*
  • 5. When sexual intercourse was attempted, how often was it satisfactory?*
  • Has a provider previously provided a prescription to treat erectile dysfunction?*
  • Was the medication helpful?*
  • Do you have a medication preference?*
  • Which erectile dysfunction medication is preferred? While preference will be taken into consideration, the provider will prescribe the medication best suited for you.*
  • Do you have a history of any of the following genital conditions? (Select ALL that apply)*
  • Do you have a history of any of the following cardiac conditions? (Select ALL that apply)*
  • Do you have a history of any of the following? (Select ALL that apply)*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)*
  • Do you have a family history of cardiovascular disease in a first degree relative (parents, sibling, child)?*

  • Early-onset cardiovascular disease is when the individual first experiences the condition, or symptoms of the condition, before the age of 55 in men and 65 in women. 

  • Using the definition (or using these ages), was the cardiovascular disease "early-onset" for your first-degree family member?*
  • Has your blood pressure been taken within the last 2 weeks?*

  • It is essential that a recent and accurate reading of your blood pressure is provided. People with high blood pressure are at an increased risk of complications when on certain birth control medications. Blood pressure can be checked for free at most pharmacies. 

    After the blood pressure is checked, please come back to this visit and enter the blood pressure below:

  • A blood pressure reading contains 2 numbers written like a fraction (e.g. 120/80; read as "120 over 80"). The higher number (120) is the "systolic" blood pressure. The lower number (80) is the "diastolic" blood pressure. 

    Please enter your blood pressure taken within the last 2 weeks below:

  • Genital Herpes Medication Refill

  • Has a provider previously diagnosed you with genital herpes?*
  • In order to provide better care, can you tell us how you were diagnosed? (Select ALL that apply)*
  • When were you diagnosed?*
  • Which symptoms have you experienced with past episodes of herpes?*
  • Do you currently have any of these symptoms? (Select ALL that apply)*
  • How many outbreaks do you normally have in a year?*
  • Do you have active sores at this time?*
  • How many sores do you currently have?*
  • Are you experiencing a similar rash or sore(s) on other parts of the body other than the genital area?*
  • Where is your sore(s) or rash located? (Select ALL that apply)?*
  • Did you notice any pain or unusual sensations (such as itching, burning, or tingling) in the location of the sore(s)/rash before it began?*
  • Do you feel feverish?*
  • Is it possible to take your temperature now?*
  • Do you take pills every day to help prevent outbreaks (preventative treatment)?*
  • What do you need a refill for?*
  • Which of these medications have you used in the past? (Select ALL that apply_*
  • Which of the following medications were effective in treating your sores in the past? (Select ALL that apply)*
  • Do you have diabetes?*
  • Which of the following statements apply to you regarding your diabetes?*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)*
  • Have you been treated for another type of sexually transmitted infection (STI) within the last 2 weeks?*
  • What sexually transmitted infection(s) (STI) were you treated for? (Select ALL that apply)*

  • Male Pattern Baldness Medication Refill

  • Male pattern baldness is a very common condition. Fortunately, there are treatments available that can help regrow hair and prevent further hair loss. 

  • Please tell us the reason for your visit today:*

  • Only minoxidil (Rogaine) and finasteride (Propecia) are offered as treatments through this visit. These medications are clinically proven to treat hair loss. 

  • Which of the following medication(s) would you like to refill? (Select ALL that apply)*
  • Has the medication(s) been effective?*
  • Please tell us why you are seeking treatment for hair loss today:*
  • Do you have any isolated bald spots on the scalp?*
  • Do you have significant hair loss on any other locations of the body besides the scalp?*
  • When did you first notice the hair loss?*
  • Did you lose a significant amount of hair in a short period of time?*
  • Are you currently experiencing any of the following on the scalp?*
  • What is the color of the affected area of your scalp?*
  • Have you noticed any abnormal changes to the nails such as pitting (tiny dents) of the nails?*
  • In the last 3 months, have you had unintended weight loss of more than 10 lbs (i.e., weight loss not due to increased exercise or dieting)?*
  • Did you have any of the following before the hair loss started?*
  • Do you have irresistible urges to pull out hair on the head or anywhere on the body?*
  • Do you frequently wear wigs or have tight braids?*
  • Do you regularly bleach, color, or perm the hair on the head?*
  • Have you ever tried any hair loss treatments?*
  • Do you have any of the following? (Select ALL that apply)*
  • Have you had chemotherapy treatment?*
  • When was your last chemotherapy treatment?*
  • Do you have a family history of male pattern baldness?*

  • Seasonal Allergies Medication Refill

  • What is the main reason for seeking help with your allergies today?*
  • Which of the following seasonal allergy symptoms do you usually get? (Select ALL that apply)*
  • Do you currently have any of these symptoms? (Select ALL that apply)*
  • Do you currently have any of these symptoms? (Select ALL that apply)*
  • Do you currently have any of these symptoms? (Select ALL that apply)*
  • When did your symptoms start?*
  • Please rate the severity of your headache on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*
  • Please rate the severity of your throat pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • What color is your mucus? (Select ALL that apply)*
  • Do you currently have difficulty breathing?*
  • Is there an unhealed sore inside the nose or a hole in your nasal septum? The nasal septum separates the two nostrils.*
  • Have you ever had allergies to pollen, dust, animal dander, or anything else in the air?*
  • How frequently do you have allergy symptoms?*
  • In the past 60 days, have you had sinus surgery?*
  • Do you feel feverish?*
  • Is it possible to take your temperature now?*
  • Have you been told by a provider to avoid NSAIDs?*
  • Do you have asthma?*
  • Does anyone in your immediate family (biological mother, father, sister, brother) have a history of asthma?*
  • Do you have hypertension (high blood pressure)?*

  • MEDICATION DETAILS

  • This visit does NOT guarantee a refill. The provider will determine if a refill is medically appropriate and how many refills can be prescribed. The visit is only intended for short-term medication refills and not intended for controlled substances, such as Adderall and Ambien. 

    Please provide details about the medication you would like refilled. Include ONLY the medication name, dosage, and how often it is taken. If possible, include both generic and brand name (e.g. Ibuprofen/Advil 200mg, 2 pills, 3 times a day). 

  • When did you start taking this medication?*
  • When did you last see a provider for this medication?*
  • When was your last physical evaluation with a provider?*
  • How many days supply for the refill would you like to request? The provider will determine if a refill is medically appropriate and how many refills can be prescribed.*
  • Are you currently taking this medication?*
  • When did you discontinue or stop taking this medication?*
  • Have you experienced any side effects with this medication?*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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