caresync.tech

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Patient Intake Information

First Name*

Last Name*

Primary Phone*

Mobile/Alt Phone

Primary Email*

Best Time To Call

Gender*

Ethnicity

DOB mm/dd/yyyy*

Age

Last 4 SS#

Height (In inches)*

Weight (In LBS)*

Billing Street Address*

Billing City*

Billing State*

Billing Zip Code*

Is billing address the same as physical address?*

Physical Street Address*

Physical City*

Physical State*

Physical Zip Code*

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Pharmacy/Prescription Insurance

Select Insurance Type

Insurance Payer Type

Insurance Company Name

Member ID

Pharmacy Group Number

Pharmacy PCN

Pharmacy BIN

Medical Insurance (For Telehealth Consult)

Select Insurance Type

Insurance Payer Type

Insurance Company Name

Payer ID

Member ID

Primary Ins Group

Primary Ins PCN

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Patient Consultation Informed Consent

I, , consent to a telemed consultation with a -licensed practitioner regarding the medical nature of my condition(s). This interaction will entail, but is not limited to, an assessment of my current medical condition(s), a summary of my symptoms and their severities, a review of the prescriptions or treatment I am currently using, their duration and effectiveness and a subsequent treatment plan if warranted. I understand that my personal health information will remain secure and protected per HIPAA guidelines.

I also understand that prescription orders (“Order”) resulting from this consultation will be filled by a local pharmacy in . Therefore, I authorize for this pharmacy to fulfill the Order by billing my insurance and shipping the Order for treatment.

I consent to have the pharmacy contact me as necessary via phone, text messages and/or the email address I have provided, for purposes that include, but are not limited to, providing me notifications when my prescriptions are shipped and scheduled for refills. I understand that communications sent via text messages over an open network or by unencrypted email are inherently unsecure and that there is no assurance of confidentiality of the information communicated in this manner. Further, I understand that additional text message fees may apply as dictated by my cellular carrier.

I understand that billing my insurance does not guarantee payment and that I may be subject to financial responsibility, including deductibles, copayments, and any other payments required by my insurance plan. However, I understand I am not obligated to use this service and may opt-out of this service at any time. I further understand that I may use any other pharmacy provider of my choice to fulfill my prescription orders. I also understand that I will need to convey my intent to opt-out of this service via verbal or written communication to the pharmacy.

Pharmacy Benefits Patient ConsentPharmacy Benefit Managers (PBM) are third party administrators of prescription drug programs who process and pay prescription drug claims and compile lists of drugs covered by your prescription drug plan.I, , consent to having 3rd party Pharmacy Benefit checks run to ensure the accuracy of insurance information and provide the highest quality patient care.

- Obtain Pharmacy Benefits through a pharmacy eligibility inquiry (E-1)

- Determine pharmacy benefits and drug copays under your medical insurance through a pharmacy benefits inquiry (B1)

- Verify if a prescribed drug is in the list of available prescriptions under your medical insurance

- Establish alternative drugs that can be substituted if a prescription is not on the list of drugs covered under your insurance

- Determine if your medical insurance allows electronic prescribing to a Retail or Mail Order Pharmacy

The pharmacy offers an auto-refill program to ensure there are no delays or disruption to therapeutic care. A patient can opt in or out of this program at any time by calling the pharmacy or sending written communication. If you want to enroll into the pharmacy’s auto-refill program, please sign again below:

The pharmacy offers an auto-refill program to ensure there are no delays or disruption to therapeutic care. A patient can opt in or out of this program at any time by calling the pharmacy or sending written communication. I want to enroll into the pharmacy’s auto-refill program.

Full Signature Here
Clear

Check if you, as the patient, are unable to complete a video telehealth consultation due to your location, available technology, or technical inexperience.

Upload your Insurance Card and/or Photo Identification 1

Upload your Insurance Card and/or Photo Identification 2

Upload your Insurance Card and/or Photo Identification 3

Upload your Insurance Card and/or Photo Identification 4

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Clinical Assessment

Do You Suffer From Any Pain

Do You Suffer From Acne You Would Like Treated?

Do you Suffer From Arthritis Joint Pain or Other Pain Caused By Inflammation

Do You Suffer From Any Pain Due To Muscle Spasms, Body Tension or Tight Muscles You Want Treated

Do You Suffer From Any Of the Following Fungal Infections Of The Skin: Ringworm, Seborrhea,Athletes Foot,Jock Itch

Do You Have Chronic Heartburn or Acid Reflux

Do You Suffer From Dry Itchy Skin, Psoriasis or Eczema

Do you get Headaches - Tension headaches, Sinus Headaches Or Migraines?

Do you need any medications refilled?

Would you like to complete a general consultation with the provider?

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Diabetes Assessment

Are you currently living with any of the following conditions?

Which type of diabetes?

Do you have any drug allergies?

What was your most recent A1c result?
(A1c typically ranges between 5.7% and 12% for Prediabetes or Type 2 Diabetes)
(Click continue if you don’t know and we will offer an at-home A1c lab test)

Patient does not know A1C result

What was the approximate date of your most recent A1c Result?

Have you ever been diagnosed with any of the following?

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Pain Assessment

Locations Of Pain

Frequency Of Pain

What Was The Cause Of The Pain

Describe Your Pain

What Makes Pain Feel Better

What Makes Pain Worse

Rate Your Pain 1 Being No Pain 10 Being Excruciating

Additional Pain Information

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Acne Assessment

Where Is The Location Of Your Acne

Do You Clean This Location Regularly

How Many Bumps Do You Have?

How many of these bumps are full of pus or fluid?

Has this caused scabbing or scaring?

What previous methods have you used to treat the acne?

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Inflammation Assessment

What Areas Are Affected By Muscle Or Joint Inflammation

How Long Have You Experienced Inflammation

Past Inflammation Treatments

Patient Interested In An Oral non-steroidal anti-inflammatory product

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Muscle Spasm Assessment

How Long Have You Been Experiencing Muscle Spasms Or Tightness

How Have You Treated Your Muscle Spasms Or Tightness

Would You Be Interested In An Oral Muscle Relaxant If The Physician Deems You A Good Candidate For This Treatment Option

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Anti Fungal Assessment

Where Is Your Fungal Skin Issue Located

How Long Have You Had Fungal Skin Issue

Have You Previously Treated This Fungal Issue

List Past Treatments For yor Fungal Infection

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Foot Bath Assessment

Would You Like To Receive Treatment For Your Foot Ulcers

Any Itching, Stinging or Burning between your toes or on Soles Of Feet

Do You Have Blisters On Your Feet That Itch

Any Cracking or Peeling Skin On feet, Between Toes or On Soles Of Feet

Do You Have Dry Skin On Soles Of Your Feet

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

GERD Irritation Assessment

How Often Do You Experience Heartburn or Acid Reflux

What Relieves Your Heartburn or Acid Reflux

Rate Your Pain 1 Being No Pain 10 Being Excruciating

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Rash and Skin Irritation Assessment

Where Is Your Rash Or Skin Irritation Located

How Long Have You Had Your Rash Or Skin Irritation

What Was The Cause Of Your Rash Or Skin Irritation

Have You Ever Treated Your Rash Or Skin Irritation before

How Did You Treat Your Rash Or Skin Irritation

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Migraine Assessment

How long have you been suffering from headaches?

Have you previously been treated for headaches?

Do you know what type of headaches they are?

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Refill Assessment

Add All Patient Medications

External Intake

Please complete & submit this form in its entirety to be contacted by a provider.

Wellness Assessment

Have you ever been told that you were vitamin deficient?

Do you currently take OTC vitamin supplements?

Please describe any other conditions that you would like to discuss with the healthcare provider.

Add All Drug Allergies

Add All Patient Medications