Telemedicine Prescription Request


Complete The Form

Complete the short form below.

Doctor Review

A US based medical professional will evaluate everything and follow up with questions.

Product Delivery

1-3 day shipping, discreet packaging and no signature needed.

Are you a new patient?

Step 2Personal Details

Please fill out your personal details to speak with an MD. All personal details are stored in a secure HIPAA compliant manner.

Step 3Telemedicine Survey | Telemed Acknowledgement

Please fill out this medical intake questionnaire honestly and completely. Your answers will be reviewed by a SpeakWithAnMD healthcare provider prior to your consultation.
Please Note: Omitting pertinent medical information could lead to lack of proper medical treatment and result in the scheduling of a new appointment in which another fee will be charged.

Step 4Telemedicine Survey | General

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Example: 190 (numerical only in pounds)

Step 5Telemedicine Survey | Seasonal Allergies

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

If no seasonal allergies, put NONE

(ex itchy watery eyes, cough, runny nose)

Step 6Telemedicine Survey | Flu Screening

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Flu Screening

(check all that apply)

Flu Screening

Flu Screening

Flu Screening

Step 7Telemedicine Survey | COVID-19

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 8Covid Treatment

Step 9Choose your Consultation Type

Please Read Carefully and Choose the Type of Consultationyou would like to recieve.



1. No Communication from Healthcare Provider - Because you have provided the clinician with an accurate and complete medical intake, they are able to determine the best course of action after reviewing your file. The healthcare provider may contact you if they have further questions.

2. Quick - Because a healthcare provider does not need to contact you, unless they have further questions, they can process your file in a more timely manner.

3. Please be aware that if you have any questions about medications, concerns about treatment or questions about your medical condition(s) this type of conult may not be right for you. Any follow up to an asynchronous consult will require an additional consultation fee.


1. Talk to a Healthcare Provider - If you have questions or concerns about your course of action, including the best medication for you, or if you would like to talk to them about medication other than those listed previously then a synchronous visit might be best for you.

2. Longer Wait Times - Because you are choosing to speak to a healthcare provider and because of the high volume of calls, it may take longer for a provider to reach you.

Please Note:
  • The healthcare provider will try to reach you 3 times, if they are unable to reach you your payment method will be voided and you will have to re-book your consultation.

  • In order to improve the chances of success of the healthcare provider reaching you, you will need to remove any call blocking. You will also need to answer any call from numbers you don’t recognize or “unknown” numbers
I would like to select the option for an Asynchronous Consult

Are you willing to waive the step of having to wait on a phone call from the physician to receive the prescription for the COVID-19 prophylaxis kit of medications?

Patient agrees that unless otherwise requested by the treating physician, doctor-patient consults shall be conducted via Asynchronous communication, and patient expressly waives the right to have doctor-patient consults conducted by way of other telehealth modalities, including but not limited to direct video communication (Synchronous), Remote Patient Monitoring, Mobile Health (mHealth), or other audio/video direct person to person collaboration.
I would like to select the option for an Synchronous Consult

Step 10Telemedicine Survey | Pharmacy Request

Please fill out a short questionnaire to help the doctor determine medical necessity for a medical prescriptions and medical advice.

Step 11Telemedicine Concierge Service

Final Step Please Review before Submission


Personal Information
First Name *
Middle Name
Last Name *
Gender
Street Address *
City *
State *
ZIP *
Date of Birth *
Phone Number *
Best Time to call you *
Email

Telemedicine Survey | Telemed Acknowledgement
Q1.By checking this box and requesting an appointment, you will be provided the opportunity to consult with a physician that is licensed in your state of residence. This does not guarantee that the requested medications will be prescribed. We rely on the experience and medical knowledge of our highly qualified physicians to provide the best patient care possible through telemedicine. *
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Q2.By checking this box you are agreeing to our terms and conditions and our refund policy refunds are made at our discretion and are not guaranteed. *
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Q3.By checking this box you are agreeing that we are independent of any pharmacy and any guarantees made regarding medication delivery are not reflected by us, medications are not included in the appointment fee. *
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Q4.The patient expressly acknowledges and consents that patient consults may be conducted by a licensed nurse practitioner or licensed physician. *
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Telemedicine Survey | General
Q1.What is your chief complaint? *
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Q2.What is your Height: *
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Q3.What is your weight: *
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Q4.What current medications are you taking? *
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Q5.Are you Diabetic? *
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Q6.Do you take oral or insulin to treat diabetes? *
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Q7.Do you have any allergies: *
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Q8.Are you allergic to any medication? *
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Q9.Have you seen doctor in last 12 months: *
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Q10.Have you recently experienced a cough or allergy symptoms? Such as runny nose, itchy eyes, or scratchy throat? *
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Q11.Do you experience Seasonal Allergies? *
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Q12.Do you often feel sluggish, lack energy, or get frequent colds or flu? *
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Q13.Do you have chronic heartburn or acid reflux? *
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Q14.Are you currently experiencing any of the following? *
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Q15.Do you experience any of the following skin issues? *
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Q16.Do you experience any of the following conditions? *
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Q17.Do you have a history of Retina Disease? *
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Q18.Do you have a history of Arrhythmia or Heart Disease? *
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Q19.Do you have a history of Seizures? *
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Q20.Do you have a history of low blood counts? *
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Q21.Do you have a history of Asthma or COPD? *
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Q22.Are you currently pregnant? *
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Telemedicine Survey | Seasonal Allergies
Q1.How long have you exhibited symptoms of seasonal allergies? *
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Q2.What symptoms do you experience? *
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Q3.Are you currently taking an anti-histamine? *
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Q4.Would you be interested in a anti-histamine if the physician deems you a good candidate for this treatment option? *
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Telemedicine Survey | Flu Screening
Q1.Are you running a fever of 100F or greater? *
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Q2.Are you experiencing any of these symptoms? *
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Q3.Have you been experiencing these symptoms for longer than 4 days? *
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Q4.Are you having trouble breathing or shortness of breath? *
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Q5.Are you currently taking any medications to self-treat your symptoms? *
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Telemedicine Survey | COVID-19
Q1.Are you experiencing any of the following symptoms: fever, cough, shortness of breath, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell? *
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Q1.1.Are you covid positive currently or exhibiting symptoms that are concerning for covid? *
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Q1.2.Do you have any chest pain? *
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Q1.3.Do you have any shortness of breath? *
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Q2.Have you been in close contact within the past 10 days with a laboratory confirmed COVID-19 case? *
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Q2.1.Are you exhibiting symptoms that are concerning for covid? *
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Q2.2.Are you wanting to receive a recommended prophylaxis kit of medications in case you become sick from being exposed to COVID-19? *
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Q2.3.Are you willing to waive the step of having to wait on a phone call from the physician to receive the prescription for the COVID-19 prophylaxis kit of medications? By selecting yes to this question, a doctor will NOT be calling you. The physician will review the intake information you provided and if approved, will be sending a prescription for the prophylaxis kit direct to our partner pharmacy. You will receive a call from the pharmacy. *
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Q2.4.Patient agrees that unless otherwise requested by the treating physician, doctor-patient consults shall be conducted via Asynchronous communication, and patient expressly waives the right to have doctor-patient consults conducted by way of other telehealth modalities, including but not limited to direct video communication (Synchronous), Remote Patient Monitoring, Mobile Health (mHealth), or other audio/video direct person to person collaboration. *
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Q3.Have you been in contact with a person hospitalized with acute lower respiratory illness of unknown origin? *
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Q4.Do you have any history of travel to or from an affected geographic area with widespread community transmission? *
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Q5.Do you have a history of international travel or a cruise? *
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Q6.Are you 65 and or older with a history of chronic health conditions? *
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Covid Treatment
Q1.Treatment Plan *
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Consultation Type
Q1.Consultation Type? *
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Telemedicine Survey | Pharmacy Request
Q1.If available, would you like your prescription delivered directly to your home? *
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Q2.Pharmacy Lookup *
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Telemedicine Concierge Service
Q1.Be treated like a movie star, athlete and the rich and famous with 24/7 medical help when you need it. Have a doctors ,nurses, pharmacists and counselors available to you whenever a need arises. We can send more information and additional benefits by clicking on I would like more information.
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Q2. Would it be okay to contact you regarding this?
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