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Male Female Other

    1 - Have you tested positive for COVID-19?*

  • Yes
    No

    • 2 - Can you provided exact date of your positive test?*


    • 3 - When do your symptoms started?*


    • 4 - Have you been Vaccinated for Covid?*

  • Yes
    No

    • 5 - if Applicable, any chance you are pregnant?*

  • Yes
    No

    • 6 - When were you vaccinated for Covid?*


    • 7 - Have you been in close contact with a positive covid person?*

  • Yes
    No

    • 8 - What type of symptoms have you expeienced? *

  • No Symptoms
    Fever
    Sore throat
    Headache
    Weakness
    Muscle Aches
    Cough
    Diarrhea
    Nausea
    Vomit
    Loss or reduction of sense of smell
    Loss or reduction of sense of taste
    Other

    • 9 - Do you have any medical conditions?*

  • Yes
    No

    • 10 - Do you take any medications at this time?*

  • Yes
    No

    • 11 - Do you have any medications Allergies?*

  • Yes
    No

    • 12 - When was the last time we saw you?*


    • 13 - Do you have any new or worserning symptoms?*

  • Yes
    No

    • 14 - Do you have any new or worserning symptoms?*


    • 15 - Are you taking any Medications right now?*

  • Yes
    No

    • 16 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
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