KosherMedications - UTI Relief

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Name* This field is required.
First Name
Last Name
2
Date of Birth* This field is required.
Date
Month
Day
Year
3
Gender* This field is required.
Please Select
Please Select
Male
Female
4
Email* This field is required.
example@example.com
5
Phone Number* This field is required.
Please enter a valid phone number.
6
What symptoms are you experiencing? (can select multiple)* This field is required.
Pain or burning when urinating
Urgent need to urinate
Increased frequency of urination
Passing small amounts of urine frequently
Cloudy urine
Strong or foul-smelling urine
Blood in urine
Lower abdominal or pelvic pain
Back or flank pain
Fever or chills
Nausea or vomiting
Other
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When did your symptoms begin? (Date or Number of Days)* This field is required.
8
Are symptoms getting better, worse, or staying the same?* This field is required.
Please Select
Please Select
Better
Worse
Same
9
Do you have a fever (above 100.4°F / 38°C)?* This field is required.
Yes
No
10
Do you have flank or back pain (below your ribs or sides)?* This field is required.
Yes
No
11
Do you have nausea or vomiting that prevents eating or drinking?* This field is required.
Yes
No
12
Do you have diabetes, kidney disease, or are you immunocompromised?* This field is required.
Yes
No
13
Have you had a catheter, stent, or urinary procedure recently?* This field is required.
Yes
No
14
Have you had three or more UTIs in the past year?* This field is required.
Yes
No
15
Are you currently pregnant or could you be pregnant?* This field is required.
Yes
No
Unsure
16
Do you have visible blood in your urine?* This field is required.
Yes
No
17
Do you have any of the following conditions?* This field is required.
Diabetes
Kidney disease or stones
Urinary retention or trouble emptying bladder
History of urologic surgery
Catheter use
Recurrent UTIs
None of the above
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Have you had any recent antibiotic use (past 3 months)?* This field is required.
Yes
No
19
List all current medications or supplements you are taking.* This field is required.
20
Do you have any known medication allergies? (if none, type N/A)* This field is required.
21
Are you currently pregnant or could be pregnant?* This field is required.
Yes
No
Unsure
Not Applicable
22
Are you breastfeeding?* This field is required.
Yes
No
Not Applicable
23
Are you currently on your menstrual period?* This field is required.
Yes
No
Not Applicable
24
Do you have vaginal discharge, itching, or odor?* This field is required.
Yes
No
Not Applicable
25
MALE SPECIFIC QUESTIONS : Have you had any discharge from the penis?* This field is required.
Yes
No
Not Applicable
26
MALE SPECIFIC QUESTIONS : Have you had pain or swelling in the testicles?* This field is required.
Yes
No
Not Applicable
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What is your pain level? ( 0=none , 10=severe)* This field is required.
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Location of Pain* This field is required.
Lower abdomen / suprapubic
Back / side / flank
Genital area
No pain
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Do you have chills or sweats?* This field is required.
Yes
No
30
Are you able to tolerate fluids and keep down oral medications?* This field is required.
Yes
No
31
Have you been sexually active in the last 30 days?* This field is required.
Yes
No
32
Have you or your partner been treated for a sexually transmitted infection recently?* This field is required.
Yes
No
33
Do you use contraception?* This field is required.
Condom
IUD
Birth Control Pills
None
Other
34
Do you void (urinate) after sexual activity?* This field is required.
Yes
No
Sometimes
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Have you had a UTI before?* This field is required.
YESNO
36
Upload recent lab or urinalysis results (if available)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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37
Any additional notes for your provider
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Delivery Address* This field is required.
Street Address
Street Address Line 2
City
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39
Upload a picture of all insurance cards ( if applicable)* This field is required.
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Select files to upload
Max. file size: 10.6MB
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40
H&P Certification* This field is required. Before obtaining your prescription, please review your Health & Physical (H&P) Certification. These statements outline the required self-assessment used to determine prescription eligibility and safety. You can view the full certification details at the link below before completing your purchase.
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You are almost there…I agree, in the form of a declaration, given under oath and penalty of perjury, that I: am 18 years or older, completing this attestation for myself voluntarily, and have provided accurate identifying and demographic information including my legal name, address, date of birth, IP address, and location I am visiting this website from. have accurately reported my sex assigned at birth, height, weight, and all requested medical information truthfully. will only use this service to seek medical evaluation and/or a prescription for myself and will not transfer, share, or sell any prescription medication I may receive to another person. understand that this attestation will be reviewed by an independent licensed provider (the “Telehealth Provider”) licensed in my state of residence, and that the Telehealth Provider’s credentials and licensing information are available on the Consent to Telehealth page on KosherMedications.com. understand that prescribing medications via telemedicine is at the professional discretion of the Telehealth Provider, and any prescription issued will follow applicable federal and state regulations and the standard of care in my state. understand that the Telehealth Provider may require additional information or a follow-up video call before issuing a prescription if deemed medically necessary. acknowledge that by completing this process, I am establishing a valid physician-patient relationship for the purposes of this telehealth encounter. Consent to Telehealth I understand and acknowledge that: The telehealth model provided through KosherMedications.com is a supplemental mode of care for convenience and access. It does not replace ongoing care or regular follow-up with my primary care provider. Due to the nature of telemedicine, the Telehealth Provider cannot: Continuously monitor my ongoing health or lab values, Directly observe my tolerance to prescribed medications, or Verify treatment effectiveness beyond this encounter. I assume any risks associated with this telehealth modality and waive any claim against KosherMedications.com or the Telehealth Provider related to these limitations. By submitting this attestation, I consent to: The use of asynchronous and/or synchronous telehealth technologies. The creation of a physician-patient relationship. The transmission and secure storage of my health data in compliance with HIPAA. The Telehealth Provider will determine, in conjunction with state and federal law, whether my condition is appropriate for telemedicine evaluation and treatment. I understand that KosherMedications.com implements encryption, password protection, and authentication protocols to safeguard privacy, but acknowledge that no system is entirely risk-free. I hold KosherMedications.com and the Telehealth Provider harmless for data lost due to technical failures and authorize the sharing of my health information with affiliated pharmacies and service partners for the purpose of completing care in accordance with HIPAA. Clinical Attestation — Urinary Tract Infection (UTI) Treatment I attest that I: am requesting evaluation and possible treatment for acute uncomplicated cystitis (a urinary tract infection limited to the bladder). understand that this treatment is not appropriate for kidney infection (pyelonephritis) or more serious infections involving fever, flank pain, or vomiting. will immediately seek in-person medical care if I develop: Fever greater than 100.4°F (38°C), Severe back/flank pain, Nausea or vomiting preventing hydration, or Worsening symptoms despite treatment. am aware of the possible medications that may be prescribed, such as Nitrofurantoin, Trimethoprim-Sulfamethoxazole, or Fosfomycin, depending on clinical appropriateness. understand that the Telehealth Provider will select the medication based on my medical history, allergies, and clinical suitability. I confirm that I: have not had an allergic reaction to Nitrofurantoin, Sulfa drugs, or any antibiotics previously used to treat urinary infections. do not have kidney disease, severe renal impairment (CrCl < 30 mL/min), or a history of cholestatic jaundice, hepatic dysfunction, or G6PD deficiency. am not currently pregnant or breastfeeding. am not experiencing flank pain, chills, or vomiting. will take the medication exactly as prescribed and complete the full course even if symptoms improve. will take Nitrofurantoin (if prescribed) with meals to minimize stomach upset and improve absorption. understand that long-term or repeated use of antibiotics may cause fungal or bacterial superinfection, and that the medication may cause nausea, diarrhea, or dark urine. understand that antibiotics may reduce the effectiveness of hormonal contraceptives and that additional birth control methods may be necessary. Additional Health & Medical Information I declare that I: am in generally good health apart from the symptoms disclosed during this visit. have provided my complete and accurate medical and medication history, including all allergies and supplements. understand that my Telehealth Provider may request additional information, labs, or video consultation before prescribing, and I agree to comply if required. understand that the Telehealth Provider will rely on the truthfulness and completeness of my responses to make a prescribing decision consistent with the standard of care. General Information About Prescription Drugs I acknowledge that: this attestation does not list all potential risks, side effects, or drug interactions. additional information can be found through official resources such as www.fda.gov or www.drugs.com/drug_interactions.html . it is my responsibility to review medication information provided by the pharmacy and to consult my primary care provider for additional medical guidance. I must report any serious side effects or allergic reactions immediately to my provider or seek emergency care if needed. Pharmacy Information I understand and acknowledge that: KosherMedications.com is a telehealth facilitation platform and does not employ or control the Telehealth Providers or the dispensing pharmacies. Independent licensed providers and pharmacies operate through KosherMedications.com but maintain their own professional and regulatory responsibilities. KosherMedications.com may transmit my prescription and relevant health information securely to a partnered pharmacy for dispensing, in compliance with HIPAA and state law. I consent to receive patient education materials, prescription information, and refill reminders electronically. I am responsible for reviewing all prescription instructions thoroughly and contacting the provider or pharmacist if I have any concerns before taking the medication. Emergency Disclaimer I understand that: neither KosherMedications.com nor its Telehealth Providers provide emergency medical services. in the event of a medical emergency, severe reaction, or sudden worsening of symptoms, I will immediately call 911 or go to the nearest emergency room. Final Declaration By checking the box and proceeding: ☑ I declare under penalty of perjury that all information I have provided is true, complete, and accurate. ☑ I understand that my telehealth visit concludes once the provider has completed their review and issued any applicable prescription. ☑ I acknowledge that I have read, understood, and agree to the KosherMedications.com Terms & Conditions available at https://koshermedications.com/terms
I agree and understand to these terms. I wish to proceed.
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