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Physician Diagnosis Questionnaire

Questions

Pharmacy

Information

Treatment

Payment

Initial Questions

Help us understand your problem
Have you used HerpAlert before?
Are you currently experiencing an outbreak?
Is this your first breakout?
Where on your body are you currently experiencing symptoms? Choose all that apply.
Please provide your email:

Pharmacy Search:

Search by Zipcode:

    Pharmacy Pick-up Information




    *

    Please double check your # as you will need it to access your case.


    WOULD YOU LIKE THE PHYSICIAN TO CALL YOU?

    Yes, I would like the physician to call me
    No, I would like to receive an online diagnosis and prescription

    NUMBER OF TREATMENTS

    On-Demand Monthly Subscription $29/mo
    • Subscribe and save $11 on today's visit.
    • Subscribe and save $50 on monthly treatments.
    • Risk Free, Cancel Anytime.
    • Diagnosis cost will not be charged on any future visit.
    Two Added Treatments $148
    • Get a prescription right now and get two refills.
    • Opt out from two future Diagnostic Costs ($90 Savings).
    Standard Treatment $79
    • Receive our standard care which includes a Diagnosis and Prescription.
    • Perfect for your first time.
    • No commitment.

    ** Initial prescriptions and refills are issued when medically appropriate, subject to physician’s medical judgment, and not guaranteed.


    Payment


    Diagnosis Cost: $79


    *One Treatment included

    Please Note the credit card statement will be noted as "H.A. Telehealth" and not HerpAlert.


    Choose a payment method below


    Credit Card
    - OR -
    PayPal

    1 Billing Information

    Consent to Telemedicine and Terms of Service

    Are you taking any prescription medication?
    What type of treatment are you looking for?
    Have you been previously diagnosed with Herpes by a physician?
    When did the symptoms start?
    What symptoms are you currently experiencing? Choose all that apply.
    Do any of the following currently apply to you? Choose all that apply.

    Do you have any known allergies to prescription medications?
    Do you have any major or relevant medical conditions that the physician should be aware of?
    When was your last outbreak?
    How many outbreaks have you had in the past year?
    Are you taking any prescription medication for herpes now?
    Are you taking any over-the-counter medications for herpes now?
    Have you previously taken any prescription medication for herpes?
    Is there any additional information that you would like your physician to be aware of?
    Select Option

    * Recommended

    TAKE A PICTURE


    • Quick Response
    • Encrypted
    • Only Visible to Doctor

    - or -

    CALL AN EXPERT


    • No Photo Required
    • Speak with a Physician

    UPLOAD PHOTOS OF THE AFFECTED AREA

    Required Photo


    Sensitive Content

    your image
    Click to show/hide picture
    - or -

    Add Optional Photo



    Case Review


    Initial Questions:

    Previously Diagnosed with HSV:
    First Outbreak:
    First Breakout:
    Symptoms Place:

    When Did Symptoms Start:
    Symptoms Type:
    Last outbreak:
    Taking Prescription Medication:
    Taking OTC Medication:
    Previously Taken Prescription Herpes Medication:
    Taking Prescription Medication For Herpes:
    Currently Applied Conditions:
    Treatment Type:
    Allergies To Prescription Medications:
    Relevant Medical Conditions:
    Outbreaks In Your Life Time:
    Additional Information:


    Images:

    Description:


    Sensitive Content

    your image


    Prescription Info:

    Name:
    Email:
    DOB:
    Address:

    Phone Number:
    Preferred Pharmacy: