Top Health Center

Name *

Date of Birth *

Email *

Phone Number *

Address *

Sex *
Male Female Other

1 - When did you first notice symptoms related to nausea or vomiting?*

2 - How frequently do the nausea and vomiting symptoms occur?*

3 - Are there any other symptoms that occur alongside nausea and vomiting?*

4 - If you've taken medications in the past, were they effective?

Please list the medication names and how long you used them (or if you are still using them). If you haven't tried any treatments, you can leave this question blank.

5 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.

6 - Do you take any medicines, vitamins, or supplements?

Please list them here.

7 - Please list any allergies you have.

Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

8 - Is there anything else related to the treatment that you'd like to ask or discuss with your medical provider?

Upload Past Medical Records *

Drop files here to upload

(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.