Female Hormone Telemedicine Visit

Current Location:*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Age (Years): *
What was your gender at birth?*

FemaleMale
This visit is NOT intended for individuals under 19 years of age. Please discontinue the visit.
This visit is intended for individuals born with the female gender. If you are male, please discontinue this visit and select the Male Hormone Visit.
Height (inches)*
Weight (lbs)*

TERMS OF SERVICE
I am NOT covered by Medicare or MedicaidI am covered by Medicare or Medicaid and I agree to the terms of the Advanced Beneficiary Notice (ABN) below
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.*

Yes, I am having an emergencyNo, I am NOT having an emergency

Please select which type visit this is for:

Initial hormone replacementRefill hormone replacement
Are your current hormone prescription(s) from us (Omnia Telehealth)?*

YesNo - another provider prescribes my hormones

Medication History

Hormones
Have you ever taken hormones of any kind (birth control pills, HRT, or natural hormones)?*

YesNo
Are you currently taking hormones of any kind (birth control pills, HRT, or natural hormones)?*

YesNo
Please list the hormones you are currently taking (include birth control pills, HRT, and natural hormones):*
Please list the hormones you have tried in the past (include birth control pills, HRT, and natural hormones):*
Are you experiencing any adverse side effects from the hormones you are currently taking?*

YesNo
Please list the adverse side effects you are experiencing from the hormones you are currently taking:*

Medication Refill Information
Please list the medication(s) you need refilled. Include medication name, dosage, and frequency (e.g., Progesterone 100mg Capsule, one capsule at night)*
Are you currently experiencing any adverse side effects related to this medication?

YesNo
Please upload a picture of your current prescription (or proof of current prescription from the pharmacy).

Cancelof

Medication History
Have you been told by a provider to avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen for pain relief?*

YesNo
Do you have any medication allergies?*

YesNo Known Drug Allergies (NKDA)
Please list your medication allergies:*
Are you currently taking any medications?*

YesNo
Please list your current medication and dose below (i.e. Wellbutrin XL 150mg tab)*

Would you like to add any additional information or questions for the provider to see?*

YesNo
Add additional information below:*

My Products

Telemedicine Visit

$39.00

Enter coupon

Total

$0.00

TERMS OF SERVICE