Ordering Telemedicine COVID-19 Rapid Test Kits


1. Complete The Form

Complete the short form below.

2. Doctor Review

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

3. Product Delivery

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

Step 1Personal Details

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

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 4Telemedicine Survey | Telemed Acknowledgement

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

Step 5Telemedicine 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 8Telemedicine Survey | COVID-19

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

Step 9Telemedicine Survey | Pharmacy Request

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

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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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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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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Are you experiencing any of the following symptoms: fever, dizziness, cough, nausea or vomiting, diarrhea, congestion or runny nose, new loss of taste or smell, chills, sore throat, headache, fatigue, muscle or body aches, shortness of breath or difficulty breathing? *
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Have you experienced any other symptoms not listed above? *
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When did you begin experiencing the symptoms indicated above? *
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Do you have any of the following medical conditions? (check all that apply) *
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If applicable, are you currently pregnant COVID19? *
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Have you been prioritized for testing by a medical professional? *
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Do you work in health care? *
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Is this your first time taking the covid-19 test? *
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In the past 14 days, have you had known or suspected exposure to the sars-cov-2 virus or a covid-19 patient? *
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Do you work in a special setting where the risk of covid-19 transmission may be high? (this may include long term care, correctional and detention facilities, homeless shelters, assisted-living facilities and group homes)? *
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Are you a resident in a special setting where the risk of covid-19 transmission may be high? (this may include long term care, correctional and detention facilities, homeless shelters, assisted-living facilities and group homes)? *
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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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