Motion Sickness Telemedicine Visit
  • Date of Birth*
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  • 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.*
  • Do you have any upcoming travel and/or activity that would cause you to have motion sickness?*
  • Have you previously experienced motion sickness?*
  • Which of these motion sickness symptoms have you experienced? (Select ALL that apply)*
  • Do you have glaucoma?*
  • Do you have hypertension?*
  • Are you being treated for high blood pressure?*
  • Has the blood pressure been well controlled over the last 3 months? (for example, no higher than 130/90 most of the time)*
  • Do you have a history of migraine headaches?*
  • Have you previously tried anything to help with motion sickness symptoms such as over-the-counter medication, prescription medications, or acupressure bands?*
  • 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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