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Are you alert and oriented, and capable to make sound medical decisions?

I am alert and oriented to place, time person and capable to make sound decisions

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Are you alert and oriented, and capable to make sound medical decisions?

I am UNABLE to make clear and sound medical decisions

I am alert and oriented to place, time person and capable to make sound decisions

Are you experiencing a life-threatening emergency?

No, my condition is stable and non-life threatening

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Are you experiencing a life-threatening emergency?

I have a life-threatening emergency 

STOP! You're not a candidate for telemedicine. Call 911

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Are you allergic to any food or
medication?

Do you have any of these medical
conditions?

Please check any of the following that you've had

Heart and Lung Problems

Psychiatric Disorder

Immune disorders:

Brain disorders:

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Would you like to provide any additional information? (We won't ask again)

Which of the following do you use?

Are you currently taking medications including over the counter drugs?

Are you currently taking medications including over the counter drugs?

Are you currently taking medications including over the counter drugs?

  • 1. Medication, Dose, Frequency Edit

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Are you breastfeeding or pregnant?
(Female only)

When was the first day of your last menstrual period (LMP)?

Select a reason for the late period

If necessary, we may send a Visit Summary to your doctor

Doctor's Information

How are you paying for your prescription?

Some insurance may reimburse for telemedicine visit and cover prescription cost at the pharmacy

No worries! We'll prescribe generic drugs and provide coupons to save you 80% on Rx

AGREEMENTS
confirmation

Refund Policy: You may request a refund or cancel at any time before we send your prescription. Our service fee is non-refundable once your prescription is sent to the pharmacy. You will be fully refunded if we are unable to send your prescription to the pharmacy.
  All services rendered by CallonDoc are provided on a non-refundable basis once the service has been provided. You may request a refund or cancel at any time before we send your prescription. You will be fully refunded if we are unable to send your prescription to the pharmacy. The customer agrees not to chargeback any credit card payment for services rendered. In the event that a customer files a chargeback other payment dispute, they will be considered to be a violation of this agreement and may be subject to collection action. A collection fee of not less than $150, in addition to any fees that may be imposed by the outside collection agency or its legal representation

Paying for your mediation: Just like any doctor's office, our consultation fee does not include the medication. I understand that the consultation fee does not cover the medication and I still have to pay out of pocket or with insurance at the pharmacy