Online BLT Consultation Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Name *FirstMiddleLastSex *MaleFemaleDate of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Email *Online Treatment Agreement *I understand that an online medical visit can be a great option for minor medical issues and not ideal for severe or life-threatening illnesses. I understand that treatment offered by prescribers of MyOnlineConsultation.com is on the basis of clinical judgment, in the absence of a complete physical examination. I agree to follow up with a doctor for in-person evaluation or seek emergency care if my symptoms worsen or do not improve in a timely manner.Patient consent to download medical history? *YesNoDo you have any condition that may render you incapable of making sound medical decisions? *Yes, I have a condition that may render you incapable of making sound medical decisionsNo, I do not have any such conditionDo you have an allergy to a particular medication? *Yes, I have a history of drug allergiesNo known drug allergiesAllergies Disclosure Clause *I hereby certify that I currently have no known drug allergies and agree to indemnify and hold harmless the reviewing prescriber and/or employees of the prescriber harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my drug allergies.List all the medicines you are allergic to. *Do you have any of these conditions? *I do NOT have any chronic medical or psychiatric conditions.Heart diseaseHypertensionLiver diseaseKidney diseaseDiabetesHigh cholesterolThyroid disorderPsychiatric conditionHIV/AIDSOther ConditionPlease describe your psychiatric condition. *Please describe your chronic medical condition. *Do you currently take any of the following medications? *TamsulosinNitrates or NitroglycerinIsosorbide dinitrate or mononitrateTerazosin or DoxazosinAlfuzosin or SilodosinAntidepressants None of these medicationsDo you currently take any other medications, including over-the-counter drugs? *YesNoList all the medications you take, including over-the-counter drugs. *Medication Disclosure Clause *I hereby certify that I am NOT currently taking any medication including OTC or supplements and agree to indemnify and hold harmless the reviewing prescriber and/or employees of the prescriber harmless from any loss, damages, liability, legal liability and expenses resulting from withholding or non-disclosure of my medication of any other vital medical information.When was your last in-person doctor visit?In the last 3 monthsIn the last 3 to 6 monthsIn the last 6 to 12 monthsOver 12 months agoHave NEVER seen a doctor in-personWhich best describes your skin type? *NormalDryOilySensitivePlease select conditions that apply to you. *Autoimmune diseaseSystemic diseaseFamily history of chronic skin disordersSkin cancerNone of the aboveOther skin conditionPlease describe your skin condition. *Do you experience any of the following cardiovascular symptoms? *Chest pain when climbing 2 flights of stairs or walking 4 city blocksUnexplained fainting or dizzinessAbnormal heart beats or rhythmsChest pain with sexual activityPain, ache, discomfort or fatigue in lower body that improves immediately with restNone of these symptoms apply to meHave you or a family member ever had: *methemoglobinemialiver diseasetaken a heart rhythm medicationNone applyAre you currently pregnant or breastfeeding? *YesNoTreatment Warning and Precaution *I understand that I should not use lidocaine topical if I am allergic to any type of numbing medicine. Patient Assertation * I hereby certify that, to the best of my knowledge, the provided information is true and accurate.Prescription will be sent to RxCompoundStore.com, 8950 SW 74th Court, Suite 101, Miami, FL 33156. Ph: 786-803-8947. *Yes, I agreeLeave a comment or feedbackDigital SignatureClear SignatureSubmit & Continue to Payment