Genital Herpes Telemedicine Visit
  • Date of Birth*
     - -
  • What was your gender at birth?*

  • Format: (000) 000-0000.

  • TERMS OF SERVICE

  • *

  • Advanced 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 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.*
  • 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?*
  • How many outbreaks do you normally have in a year?*
  • Do you currently have any of these symptoms? (Select ALL that apply)*
  • Do you have active sores at this time?*
  • Are the sores located together, in a cluster?*
  • Are you experiencing a similar rash or sore(s) on other parts of the body other than the genital area?*
  • 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?*
  • Have you taken a medication for genital herpes before?*
  • 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)*
  • Have you been treated for another type of sexually transmitted infection (STI) within the last 2 weeks?*
  • What sexually transmitted infection (STI) were you treated for? (Select ALL that apply)*

  • MEDICAL HISTORY

  • Do you feel feverish?*
  • Are you able to check your temperature or have you checked it within the last 12 hours?*
  • Do you have diabetes?*
  • Have you had a hemoglobin A1c taken in the last 6 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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