Anxiety and Depression Telemedicine Visit
  • Date of Birth*
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  • 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.*
  • Please select the reason for this visit:*

  • GAD-7 Questionnaire

  • Rows

  • PHQ-9 Questionnaire

  • Rows
  • How difficult have these problems made it for you to do work, take care of things at home, or get along with other people?*
  • Have you ever been diagnosed with anxiety?*
  • Have you ever been diagnosed with depression?*
  • Have you ever been prescribed medications for anxiety or depression?*
  • Are you currently taking medication(s) for anxiety and/or depression?*
  • How would you like to change/adjust your current medication for anxiety and/or depression?*
  • Have you had any suicidal thoughts or thoughts of self-harm within the last 4 weeks?*

  • Discontinue this visit and schedule an in-person visit with your provider. If you are currently having suicidal thoughts or thoughts of self-harm, immediately call 911 or go to the emergency room. 

  • MEDICAL HISTORY

  • 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?*

  • My Products*

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