Cold Sore Telemedicine 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.*
  • What are you requesting treatment for?*
  • Do you have active sores at this time?*
  • Are you experiencing any cold sore symptoms?*
  • Has a provider previously diagnosed you with cold sores (herpes simplex 1)?*
  • When did your current symptoms start?*
  • Where are your sores located? (Select ALL that apply)*
  • Are the sores only on one side of your face?*
  • Are the sores located together, in a cluster?*
  • Are you experiencing similar sores on other parts of the body other than the mouth area?*
  • How many sores do you currently have?*
  • Are you experiencing any of the following symptoms? (Select ALL that apply)*
  • Do you feel feverish?
  • Have you taken your temperature in the last 24 hours or are you able to take your temperature now?*
  • Did you notice any pain or unusual sensations (such as itching, burning, or tingling) in the location of the sores/rash before it began?*
  • When was the last time you had an outbreak?*
  • Do your sores typically go away and come back?*


  • Treatment for various skin conditions may vary based on different skin tones.

  • Please select your skin tone:*
  • Have you taken any prescription medications for treating the sores in the past?*
  • Which of these prescription medications were effective in treating the sores in the past?*
  • In the past 12 months, have you taken oral antivirals for long term suppression of the oral sores?*
  • How long ago did you complete the last course of treatment?*
  • Are you able to upload a picture of the affected area? (You may be required to upload a picture before the visit can be completed)*
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  • MEDICAL HISTORY

  • Do you have diabetes?*
  • Have you had a hemoglobin A1C taken in the last 5 months?*
  • Please select the HgbA1c range that accurately reflects your result:*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)*
  • 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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