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Male Female Other

    1 - What best describes the symptom that you're seeking help for today? *

  • Redness
    Scratch marks
    Bumps, spots or blisters
    Dry, cracked skin
    Leathery or scaly patches

    • 2 - Where are these symptoms located? *

  • Everywhere
    Face
    Neck
    Arms
    Elbows
    Hands
    Chest/abdomen
    Back
    Genitals
    Legs
    Knees
    Ankles
    None of these apply

    • 3 - Are there additional places where the symptoms can be found? *


    • 4 - How long have you experienced these symptoms?*

  • Less than a week
    Greater than a week

    • 5 - Is there anything that you have noticed that seems to make the symptoms occur more often?*


    • 6 - Have you had dry skin or red patches that itch, crust or scale easily despite over-the-counter treatment? *

  • Yes
    No

    • 7 - How many times per year do you notice these symptoms?*


    • 8 - Do any family members have a similar type of rash?*

  • Yes
    No

    • 9 - Have you tried any treatments in the past?*

  • Yes
    No

    • 10 - Was your past treatment effective?


    • Please also 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.

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


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


    • Please list them here.

    13 - 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.

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


    • 15 - Do you have a preferred treatment?*

  • No preference
    Hydrocortisone Cream 2.5%
    Triamcinolone Cream 0.1%
    Triamcinolone Ointment 0.1%
    Prednisone Tablet
    Hydroxzine Tablet|(Generic Vistaril®)
    Clotrimazole 1% Cream|
    • Don't worry if you're not sure. Your doctor will help you pick the best one for you.

    16 - Do you have a preferred dose or strength?


    • 17 - 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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