New Acute COVID Infection Patient History

New Acute COVID Infection History

New Acute COVID Infection Patient History


Patient Sex

COVID History

Are you having any of the following?
If you are having any of the above symptoms, for how many days have you been having them?
If you have had a COVID-19 test, what was the result?
How Many COVID Vaccine Shots (Including Boosters) Have You Had?
How many previous COVID-like illnesses have you had during which you tested positive for COVID-19 infection?

General Health

Do you have any of these chronic conditions?
Are you a member of any of these COVID high risk groups?
The chain pharmacies are refusing to fill ivermectin prescriptions. The followingpharmacies have such prescriptions. Select one or make your own suggestion if you know they take such prescriptions:
TeleHealth & Follow-Up Authorization: I give permission to this office to treat me bymeans of telehealth services pursuant to Governor Newsom's Order of April 3, 2020,to communicate with me through the email address provided above
Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D.,J.D., CA Medical License #G67169 provides this NOTICE TO CONSUMERS: Medicaldoctors are licensed and regulated by the Medical Board of California (800) Click "yes" to acknowledge receipt of this legally required notice.

Services Provided & Payment Requested: Upon submission of the above information, Dr. Fox will review it and send you a recommendation for treatment of your COVID-19 infection. If you wish to have this telemedicine service provided, please send $100 by the Zelle payment transfer service to phone number 408-402-2452. Upon receipt of your payment your prescriptions will be sent to your requested pharmacy and copies of those prescriptions will be sent to you at your listed email address.

Do you wish to proceed under the above agreement?
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