Subject
Name
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
Note: All customer and patient records are guaranteed to be private as protected by Federal HIPPA laws, and these records can only be released to outside parties with the signed permission of the patient.
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Chronic Illness
*
Do you have a history of chronic illness, such as heart, lung, or other inflammatory issues? If you answer "yes," please elaborate below, thank you.
Yes
No
Details
Drug Allergies
*
Do you have any known drug allergies? If you answer "yes," please elaborate below, thank you.
Yes
No
Details
Medication
*
Are you currently on any medication? If you answer "yes," please elaborate below, thank you.
Yes
No
Details
Sulfa / Chemicals
*
Do you have any sulfa and or chemical sensitivities? If you answer "yes," please elaborate below, thank you.
Yes
No
Covid Status
Have you or anyone in your household had any of the following symptoms in the last 21 days? Please check all that apply. If you answer "yes" to any of the prompts, please elaborate below, thank you.
Sore throat
Cough
Chills
Body aches for unknown reasons
SOB for unknown reasons
Loss of smell
Loss of taste
Fever at or above 100 degrees Fahrenheit
Details
Exposure
Have you been in contact with and or exposed to anyone who has tested positive for COVID-19? If you answer "yes," please elaborate below, thank you.
Yes
No
Details
Date Exposed
If you have been exposed, please indicate the date below, thank you.
MM
DD
YYYY
Symptoms
Are you experiencing any symptoms? If you answer "yes," please elaborate below, describing the severity of said symptoms, thank you.
Yes
No
Details
Testing
Have you been formally tested for COVID-19?
Yes
No
COVID-19 Medication
If you have COVID-19 symptoms, have you taken any medication to alleviate them? If you answer "yes," please elaborate below, thank you.
Yes
No
Details
Vaccines
Have you received one or more does of a COVID-19 vaccine. Please check all that apply. If you answer "yes," please elaborate below, thank you.
Pfizer
Moderna
Johnson & Johnson
A combination of companies
A different company and or pill, etc.
No, I have not received a vaccine at this time.
Details
Pharmacy Instructions