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Physician Consultation Fee - ONLY
$ 99.00
Our doctors offer a positive consultation through phone or email. The doctor will discuss your positive result, and how to correctly treat it.
To receive this referral through one of our doctors, please copy the information below, paste it in a reply to this email and fill in the form below completely then return to- vince@rapidscreenings.com
***There is a $99 fee for our doctors' consultation***
***This covers the consultation ONLY, any medication needed must be paid for by you at your pharmacy***
***It can take up to 3 days for our doctor to contact you***
Patient Information
Patient Name:
Date of Birth:
Gender:
Address:
Phone Number:
OK to leave Phone Message -Y/N
Email Address:
OK to Email Treatment Plan - Y/N
Race or Ethnicity:
Test Date:
Symptoms:
Requesting Treatment For:
Medical History
Drug Allergies:
Current Medications:
Previous Surgeries:
Medical Conditions:
Anything about your health the Physician needs to know:
Pharmacy Information
Pharmacy Name:
Address:
Phone Number: