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Male Female Other

    1 - When did you first notice your pink eye?*


    • 2 - Are you experiencing symptoms in one eye or both?*

  • One eye
    Both eyes

    • 3 - Are you currently having or recently had any upper respiratory symptoms?*

  • Yes
    No

    • 4 - Have you noticed any discharge?*

  • Yes, watery discharge
    Yes, thick discharge
    No discharge

    • 5 - Have you recently been diagnosed with an ear infection?*

  • Yes
    No

    • 6 - Does your pink eye occur seasonally when pollen counts are high?*

  • Yes
    No
    Not Sure

    • 7 - Do any of the following conditions apply to you?*

  • Havy fever
    Asthma
    Eczema
    None of these apply to me

    • 8 - Do you use contact lenses?*

  • Yes
    No

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


    • 10 - Do you take any medicines, vitamins, or supplements?


    • Please list them here.

    11 - 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.

    12 - Do you have a preference on medication type? *

  • No preference
    Oral treatment
    Eye ointment
    Eye drops

    • 13 - 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
Yes, I've read the Disclaimer Form.