Dial the Dr. Patient Form

*If you are having a medical emergency, dial 911 now*

Patient information is always secure, confidential and HIPAA protected.

Reason for Doctor Request

Briefly summarize today's medical issue/reason for consultation.

You may upload images/photos of your issue here if applicable. (always secure and confidential)

Add file

Please upload a file

Contact Information

Patient's Last Name

Patient's First Name

Parent's Last Name

For child-visit only - complete parent's name here. If this visit is not for a child, leave field empty.

Parent's First Name

Contact Phone Number (please include area code)

Patient's Full Home Address

Personal Information

Name of your preferred Pharmacy

location of your choice where your prescription is sent

Phone number of your Pharmacy

Patient's Date of Birth

Male

Female

Height

Weight

Proof of Identity: Upload photos below

Upload Gov. Issued Photo ID here driver's license, passport, etc.

Add file

Please upload a file

Upload Photo of yourself here you may take a selfie if you do not have one

Add file

Please upload a file

Medical History

Have you had any major events in your medical history?

Yes

If yes, list them here.

Have you had any major surgeries?

Yes

If yes, list them here.

Do you have any ongoing medical problems?

Yes

If yes, list them here.

Are you currently taking any medications?

Yes

If yes, list medications (DRUG NAME, FREQUENCY, DOSE)

Do you have any family health history you are aware of?

Yes

If yes, list them here.

Allergy Information

Do you have any food allergies?

Yes

If yes, list them here.

Do you have any environmental allergies?

Yes

If yes, list them here.

Do you have any medication allergies?

Yes

If yes, list them here.

Do you acknowledge and agree to the Terms & Conditions and HIPAA Privacy Notice as outlined on www.dialtheDr.com under "Terms"? Print the HIPAA Privacy Notice for your records

Yes

Note: Upon submitting this form, please check the email you provided us for any important notifications (from donotreply@hushmail.com, our secure system or Dial the Dr.) about next steps for your Dial the Dr. visit today.
We look forward to assisting you with your medical needs today!

Signed

Type your full name

Today's Date

Your information will be encrypted.