Mastitis 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.*
  • Do you breastfeed and/or pump breast milk?*
  • How long have you been breastfeeding and/or pumping?*
  • When did your symptoms start?*
  • Which breast is affected?*
  • Do you currently have any of the following symptoms on or around the breast? (Select ALL that apply)*
  • What is the color of the affected area? (Select ALL of the above)*
  • Do you currently have any of the following symptoms? (Select ALL that apply)*
  • Please rate the severity of the breast pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Does the painful area feel like there is a pocket of fluid trapped under the skin?*
  • What does the discharge from your breast look like? (Select ALL that apply)*
  • Do you currently have any of the following symptoms? (Select ALL that apply)*
  • Have you noticed a decrease in your milk supply or output?*
  • Do you have any of the following symptoms? (Select ALL that apply)*
  • Do you feel feverish?*
  • Are you able to take your temperature now or have you taken it in the last 12 hours?*
  • How long have you felt feverish?*
  • Have you ever been diagnosed with mastitis?*
  • Within the last 7 days, have you been treated with antibiotics for mastitis?*

  • STOP!

    PLEASE DISCONTINUE VISIT

  • MEDICAL HISTORY

  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)*

  • Some people have risk factors for a certain type of infection of the breast called MRSA. It is important to identify this type of infection since standard antibiotic treatment may not be appropriate.

  • In the past 12 months, have any of the following applied to you? (Select ALL that apply)*
  • Have any of the following ever applied to you? (Select ALL that apply)*
  • Have any of the following ever applied to you? (Select ALL that apply)*

  • One of the treatments used for people at risk for MRSA infections cannot be used in certain situations.

  • Do any of the following apply? (Select ALL that apply)*
  • Have you been told by a provider to avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen for pain relief?*
  • 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 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?*
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