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Allergy Questionaire
To ensure your provider can safely evaluate your symptoms, we’ll ask a few questions about your health history, medications, and allergies.
Please identify all your current medical conditions
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Please list all your current medications including dosages.
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Please list all of your known allergies.
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[HideColumn 66 in #o01d6143947f0] [HideBlock #oe4ddf5b999ab] [IfAnchor #background.01][ShowBlock #oe4ddf5b999ab][HideBlock #o01d6143947f0][Redirect #donetop][/IfAnchor] [Calc f2233//f2294=f2294][Calc f2233//f2295=f2295][Calc f2233//f2296=f2296] [Validate #o01d6143947f0-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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[HideColumn 66 in #oe4ddf5b999ab][HideBlock #o4d986e7921b0,#occ07e9ff126b][IfAnchor #sex.01][HideBlock #oe4ddf5b999ab][ShowBlock #o4d986e7921b0][Redirect #donetop][FillField f2233//f2297 with "Male"][/IfAnchor][IfAnchor #sex.02][HideBlock #oe4ddf5b999ab][ShowBlock #occ07e9ff126b][Redirect #donetop][FillField f2233//f2297 with "Female"][/IfAnchor]
[HideColumn 66 in #occ07e9ff126b][HideBlock #o02adab360d9e][IfAnchor #ab.01][HideBlock #occ07e9ff126b][ShowBlock #o2eec809b91b2][Redirect #donetop][FillField f2325 with "Yes"][/IfAnchor][IfAnchor #ab.02][HideBlock #occ07e9ff126b][ShowBlock #o02adab360d9e][Redirect #donetop][FillField f2325 with "No"][/IfAnchor]
I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.

​​​​​​​I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.

I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.

By selecting  below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
[HideColumn 66 in #o02adab360d9e][IfAnchor #f2327.01][HideBlock #o02adab360d9e][ShowBlock #o4d986e7921b0][Redirect #donetop][FillField f2327 with "I have read and understand the above information, I understand the risks and wish to proceed"][/IfAnchor][IfAnchor #f2327.02][HideBlock #o02adab360d9e][ShowBlock #obca0a66ea4f8][Redirect #donetop][FillField f2327 with "I have read the information and do NOT wish to proceed"][/IfAnchor]
What is your height?
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What is your weight in pounds
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[HideColumn 66 in #o4d986e7921b0] [HideBlock #o7a3375b623fc] [IfField f2298 not '' and f2299 not '' and f2300 not ''][ShowElement 81 in #o4d986e7921b0][HideElement 82 in #o4d986e7921b0][/IfField] [IfAnchor #measurements.01][ShowBlock #o7a3375b623fc][HideBlock #o4d986e7921b0][Redirect #donetop][/IfAnchor] [Calc f2233//f2298=f2298][Calc f2233//f2299=f2299][Calc f2233//f2300=f2300] [Validate #o4d986e7921b0-f2298 numeric "Must be Numeric values" force=yes][Validate #o4d986e7921b0-f2299 numeric "Must be Numeric values" force=yes][Validate #o4d986e7921b0-f2300 numeric "Must be Numeric values" force=yes][Validate #o4d986e7921b0-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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Current Symptoms

How long has this current rash been present?
[HideColumn 66 in #o7a3375b623fc][HideBlock #o14e78b2ef1c1] [IfAnchor #f2329.$choice][ShowBlock #o14e78b2ef1c1][HideBlock #o7a3375b623fc][Redirect #donetop][/IfAnchor] [IfAnchor #f2329.01][FillField f2329 with "Less than 24 hours"][/IfAnchor] [IfAnchor #f2329.02][FillField f2329 with "1–3 days"][/IfAnchor] [IfAnchor #f2329.03][FillField f2329 with "4–7 days"][/IfAnchor] [IfAnchor #f2329.04][FillField f2329 with "1–4 weeks"][/IfAnchor] [IfAnchor #f2329.05][FillField f2329 with "More than 1 month"][/IfAnchor] [IfAnchor #f2329.06][FillField f2329 with "More than 6 months"][/IfAnchor]

Current Symptoms

Is this the first time you have had this rash, or has it occurred before?
[HideColumn 66 in #o14e78b2ef1c1][HideBlock #o79bd477b7c8f,#oc7489a1494be] [IfAnchor #f2331.$choice][HideBlock #o14e78b2ef1c1][Redirect #donetop][/IfAnchor] [IfAnchor #f2331.01][ShowBlock #oc7489a1494be][FillField f2329 with "First time"][/IfAnchor] [IfAnchor #f2331.02][ShowBlock #o79bd477b7c8f][FillField f2329 with "I’ve had a similar rash before in the same area"][/IfAnchor] [IfAnchor #f2331.03][ShowBlock #o79bd477b7c8f][FillField f2329 with "I’ve had similar rashes before in other areas"][/IfAnchor] [IfAnchor #f2331.04][ShowBlock #o79bd477b7c8f][FillField f2329 with "This is a long-term, ongoing skin condition"][/IfAnchor]
[HideColumn 66 in #o79bd477b7c8f][HideBlock #ode9c3d3a5326] [IfAnchor #f2333.01][ShowBlock #ode9c3d3a5326][HideBlock #o79bd477b7c8f][Redirect #donetop][FillField f2333 with "Yes I know the diagnosis"][/IfAnchor] [IfAnchor #f2333.02][ShowBlock #oc7489a1494be][HideBlock #o79bd477b7c8f][Redirect #donetop][FillField f2333 with "No I don’t have a diagnosis"][/IfAnchor]
Please provide more information about this diagnosis
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[HideColumn 66 in #ode9c3d3a5326][SyncFields f2335] [IfField f2335 not ''][ShowElement 81 in #ode9c3d3a5326][HideElement 82 in #ode9c3d3a5326][/IfField] [IfAnchor #f2335.continue][ShowBlock #oc7489a1494be][HideBlock #ode9c3d3a5326][Redirect #donetop][/IfAnchor] [Validate #ode9c3d3a5326-f2323 IBAN “Please enter a valid IBAN” prevent=yes]
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Current Symptoms

Where on your body is the rash currently located? (Select all that apply)
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[HideColumn 66 in #oc7489a1494be][HideBlock #o404327d0a0be,#oaa9ea54cda66] [SyncFields f2375,f2377,f2379,f2381,f2383,f2385,f2387,f2389,f2391,f2393,f2395,f2397,f2399] [IfField f2375 is unchecked and f2377 is unchecked and f2379 is unchecked and f2381 is unchecked and f2383 is unchecked and f2385 is unchecked and f2387 is unchecked and f2389 is unchecked and f2391 is unchecked and f2393 is unchecked and f2395 is unchecked and f2397 is unchecked and f2399 is unchecked][ShowElement 89 in #oc7489a1494be][/IfField][IfField (f2375 is checked OR f2377 is checked OR f2379 is checked OR f2381 is checked OR f2383 is checked OR f2385 is checked OR f2387 is checked OR f2389 is checked OR f2391 is checked) AND f2393 is unchecked AND f2395 is unchecked AND f2397 is unchecked AND f2399 is unchecked][ShowElement 88 in #oc7489a1494be][/IfField][IfField f2393 is checked OR f2395 is checked OR f2397 is checked][ShowElement 91 in #oc7489a1494be][/IfField][IfField f2399 is checked and f2393 is unchecked AND f2395 is unchecked AND f2397 is unchecked][ShowElement 106 in #oc7489a1494be][/IfField] [IfAnchor #oc7489a1494be.01][ShowBlock #oaa9ea54cda66][HideBlock #oc7489a1494be][Redirect #donetop][/IfAnchor][IfAnchor #oc7489a1494be.02][ShowBlock #o2eec809b91b2][HideBlock #oc7489a1494be][Redirect #donetop][/IfAnchor][IfAnchor #oc7489a1494be.03][ShowBlock #o404327d0a0be][HideBlock #oc7489a1494be][Redirect #donetop][/IfAnchor]
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Please provide more information about the other location of your rash
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[HideColumn 66 in #o404327d0a0be][SyncFields f2337] [IfField f2337 not ''][ShowElement 81 in #o404327d0a0be][HideElement 82 in #o404327d0a0be][/IfField] [IfAnchor #f2337.continue][ShowBlock #][HideBlock #o404327d0a0be][Redirect #donetop][/IfAnchor] [Validate #o404327d0a0be-f2323 IBAN “Please enter a valid IBAN” prevent=yes]
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[HideColumn 66 in #oaa9ea54cda66][HideBlock #o9654daae2040] [IfAnchor #f2339.01][ShowBlock #o9654daae2040][HideBlock #oaa9ea54cda66][Redirect #donetop][FillField f2339 with "Yes, it has spread to new areas"][/IfAnchor] [IfAnchor #f2339.02][ShowBlock #o9654daae2040][HideBlock #oaa9ea54cda66][Redirect #donetop][FillField f2339 with "No, it has stayed in the same area"][/IfAnchor]

Current Symptoms

How would you describe the look of the rash? (Select all that apply)
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[HideColumn 66 in #o9654daae2040][HideBlock #o00a7c606ed2c] [SyncFields f2401,f2403,f2405,f2407,f2409,f2411,f2413,f2415,f2417][IfField f2401 is checked or f2403 is checked or f2405 is checked or f2407 is checked or f2409 is checked or f2411 is checked or f2413 is checked or f2415 is checked or f2417 is checked][ShowElement 88 in #o9654daae2040][HideElement 89 in #o9654daae2040][/IfField] [IfAnchor #o9654daae2040.01][ShowBlock #o00a7c606ed2c][HideBlock #o9654daae2040][Redirect #donetop][/IfAnchor]
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Current Symptoms

What is the main color of the rash now?
[HideColumn 66 in #o00a7c606ed2c][HideBlock #od6939d0c1c35] [IfAnchor #f2341.$choice][ShowBlock #od6939d0c1c35][HideBlock #o00a7c606ed2c][Redirect #donetop][/IfAnchor] [IfAnchor #f2341.01][FillField f2341 with "Skin-colored"][/IfAnchor] [IfAnchor #f2341.02][FillField f2341 with "Pink or red"][/IfAnchor] [IfAnchor #f2341.03][FillField f2341 with "Brown"][/IfAnchor] [IfAnchor #f2341.04][FillField f2341 with "Gray or violaceous"][/IfAnchor] [IfAnchor #f2341.05][FillField f2341 with "White or lighter than surrounding skin"][/IfAnchor] [IfAnchor #f2341.06][FillField f2341 with "Yellow or honey-colored crust"][/IfAnchor]

Current Symptoms

Do you have any of the following in the rash area? (Select all that apply)
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[HideColumn 66 in #od6939d0c1c35][HideBlock #oc29a822d28cc] [SyncFields f2419,f2421,f2423,f2425,f2427,f2429,f2431] [IfField f2419 is checked or f2421 is checked or f2423 is checked or f2425 is checked or f2427 is checked or f2429 is checked or f2431 is checked][ShowElement 88 in #od6939d0c1c35][HideElement 89 in #od6939d0c1c35][/IfField] [IfField f2431 is checked][FillField f2419,f2421,f2423,f2425,f2427,f2429 with unchecked][/IfField] [IfField f2419 is checked or f2421 is checked or f2423 is checked or f2425 is checked or f2427 is checked or f2429 is checked][FillField f2431 with unchecked][/IfField] [IfAnchor #od6939d0c1c35.01][ShowBlock #oc29a822d28cc][HideBlock #od6939d0c1c35][Redirect #donetop][/IfAnchor]
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Current Symptoms

Since the rash started, have you had any of the follow (Select all that apply)
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[HideColumn 66 in #oc29a822d28cc][HideBlock #oa8ceae2df6c2] [SyncFields f2433,f2435,f2437,f2439,f2455,f2457,f2459,f2461,f2463,f2465] [IfField f2433 is unchecked and f2435 is unchecked and f2437 is unchecked and f2439 is unchecked and f2455 is unchecked and f2457 is unchecked and f2459 is unchecked and f2461 is unchecked and f2463 is unchecked and f2465 is unchecked][ShowElement 89 in #oc29a822d28cc][/IfField][IfField f2465 is checked][ShowElement 88 in #oc29a822d28cc][FillField f2433,f2435,f2437,f2439,f2455,f2457,f2459,f2461,f2463 with unchecked][/IfField][IfField f2433 is checked OR f2435 is checked OR f2437 is checked OR f2439 is checked OR f2455 is checked OR f2457 is checked OR f2459 is checked OR f2461 is checked OR f2463 is checked][FillField f2465 with unchecked][ShowElement 91 in #oc29a822d28cc][/IfField] [IfAnchor #oc29a822d28cc.01][ShowBlock #oa8ceae2df6c2][HideBlock #oc29a822d28cc][Redirect #donetop][/IfAnchor][IfAnchor #oc29a822d28cc.02][ShowBlock #o2eec809b91b2][HideBlock #oc29a822d28cc][Redirect #donetop][/IfAnchor]
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[HideColumn 66 in #oa8ceae2df6c2][HideBlock #o4b93390dbf7b,#o3129850efa51] [IfAnchor #f2343.01][ShowBlock #o4b93390dbf7b][HideBlock #oa8ceae2df6c2][Redirect #donetop][FillField f2343 with "Yes"][/IfAnchor] [IfAnchor #f2343.02][ShowBlock #o3129850efa51][HideBlock #oa8ceae2df6c2][Redirect #donetop][FillField f2343 with "No"][/IfAnchor]

Past Treatments

What treatments have you used for this rash or similar rashes? (Select all that apply)
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[HideColumn 66 in #o4b93390dbf7b][HideBlock #oa39e55713d81] [SyncFields f2467,f2469,f2471,f2473,f2535,f2537,f2539,f2541,f2543,f2545,f2547] [IfField f2467 is unchecked AND f2469 is unchecked AND f2471 is unchecked AND f2473 is unchecked AND f2535 is unchecked AND f2537 is unchecked AND f2539 is unchecked AND f2541 is unchecked AND f2543 is unchecked AND f2545 is unchecked AND f2547 is unchecked][ShowElement 89 in #o4b93390dbf7b][HideElement 88 in #o4b93390dbf7b][/IfField] [IfAnchor #o4b93390dbf7b.01][ShowBlock #oa39e55713d81][HideBlock #o4b93390dbf7b][Redirect #donetop][/IfAnchor]
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Please specify the exact treatment you used and when you last used it
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[HideColumn 66 in #oa39e55713d81][SyncFields f2345][HideBlock #o261c257a2918] [IfField f2345 not ''][ShowElement 81 in #oa39e55713d81][HideElement 82 in #oa39e55713d81][/IfField] [IfAnchor #f2345.continue][ShowBlock #o261c257a2918][HideBlock #oa39e55713d81][Redirect #donetop][/IfAnchor] [Validate #oa39e55713d81-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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Past Treatments

Have you attempted to treat this rash?
[HideColumn 66 in #o261c257a2918] [IfAnchor #f2347.01][ShowBlock #o3129850efa51][HideBlock #o261c257a2918][Redirect #donetop][FillField f2347 with "My rash completely resolved but has returned"][/IfAnchor] [IfAnchor #f2347.02][ShowBlock #o3129850efa51][HideBlock #o261c257a2918][Redirect #donetop][FillField f2347 with "My rash improved but did not completely go away"][/IfAnchor] [IfAnchor #f2347.03][ShowBlock #o3129850efa51][HideBlock #o261c257a2918][Redirect #donetop][FillField f2347 with "No change"][/IfAnchor] [IfAnchor #f2347.04][ShowBlock #o3129850efa51][HideBlock #o261c257a2918][Redirect #donetop][FillField f2347 with "My rash worsened with treatment"][/IfAnchor] [IfAnchor #f2347.05][ShowBlock #o3129850efa51][HideBlock #o261c257a2918][Redirect #donetop][FillField f2347 with "I am not sure"][/IfAnchor]
[HideColumn 66 in #o3129850efa51][HideBlock #of99cb7d9c5e6,#ob4a647c3e2ad] [IfAnchor #f2349.01][ShowBlock #of99cb7d9c5e6][HideBlock #o3129850efa51][Redirect #donetop][FillField f2349 with "Yes"][/IfAnchor] [IfAnchor #f2349.02][ShowBlock #ob4a647c3e2ad][HideBlock #o3129850efa51][Redirect #donetop][FillField f2349 with "No"][/IfAnchor]
Please describe what you had a reaction to and what symptoms that you experienced
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[HideColumn 66 in #of99cb7d9c5e6][SyncFields f2351] [IfField f2351 not ''][ShowElement 81 in #of99cb7d9c5e6][HideElement 82 in #of99cb7d9c5e6][/IfField] [IfAnchor #f2351.continue][ShowBlock #ob4a647c3e2ad][HideBlock #of99cb7d9c5e6][Redirect #donetop][/IfAnchor] [Validate #of99cb7d9c5e6-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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Skin Rash Cause

Do you think anything triggered this rash? (Select all that apply)
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[HideColumn 66 in #ob4a647c3e2ad][HideBlock #oa03b4451b7cb,#o3f96648f4ac4] [SyncFields f2549,f2551,f2553,f2555,f2557,f2559,f2561,f2563,f2565,f2567,f2569,f2571,f2573] [IfField f2549 is unchecked AND f2551 is unchecked AND f2553 is unchecked AND f2555 is unchecked AND f2557 is unchecked AND f2559 is unchecked AND f2561 is unchecked AND f2563 is unchecked AND f2565 is unchecked AND f2567 is unchecked AND f2569 is unchecked AND f2571 is unchecked AND f2573 is unchecked][ShowElement 89 in #ob4a647c3e2ad][/IfField][IfField f2573 is checked][ShowElement 88 in #ob4a647c3e2ad][FillField f2549,f2551,f2553,f2555,f2557,f2559,f2561,f2563,f2565,f2567,f2569,f2571 with unchecked][/IfField][IfField f2549 is checked OR f2551 is checked OR f2553 is checked OR f2555 is checked OR f2557 is checked OR f2559 is checked OR f2561 is checked OR f2563 is checked OR f2565 is checked OR f2567 is checked OR f2569 is checked OR f2571 is checked][FillField f2573 with unchecked][ShowElement 91 in #ob4a647c3e2ad][/IfField] [IfAnchor #ob4a647c3e2ad.01][ShowBlock #oa03b4451b7cb][HideBlock #ob4a647c3e2ad][Redirect #donetop][/IfAnchor][IfAnchor #ob4a647c3e2ad.02][ShowBlock #o3f96648f4ac4][HideBlock #ob4a647c3e2ad][Redirect #donetop][/IfAnchor]
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Skin Rash Cause

Please tell us more about your suspected exposure
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[HideColumn 66 in #o3f96648f4ac4][SyncFields f2353] [IfField f2353 not ''][ShowElement 81 in #o3f96648f4ac4][HideElement 82 in #o3f96648f4ac4][/IfField] [IfAnchor #f2353.continue][ShowBlock #oa03b4451b7cb][HideBlock #o3f96648f4ac4][Redirect #donetop][/IfAnchor] [Validate #o3f96648f4ac4-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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Additional Information

Please select all that apply to you
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[HideColumn 66 in #oa03b4451b7cb][HideBlock #o5a080dd288c3] [SyncFields f2575,f2577,f2579,f2581,f2583,f2585,f2587,f2589] [IfField f2575 is unchecked AND f2577 is unchecked AND f2579 is unchecked AND f2581 is unchecked AND f2583 is unchecked AND f2585 is unchecked AND f2587 is unchecked AND f2589 is unchecked][ShowElement 89 in #oa03b4451b7cb][HideElement 88 in #oa03b4451b7cb][/IfField][IfField f2589 is checked][FillField f2575,f2577,f2579,f2581,f2583,f2585,f2587 with unchecked][/IfField][IfField f2575 is checked OR f2577 is checked OR f2579 is checked OR f2581 is checked OR f2583 is checked OR f2585 is checked OR f2587 is checked][FillField f2589 with unchecked][/IfField] [IfAnchor #oa03b4451b7cb.01][ShowBlock #o5a080dd288c3][HideBlock #oa03b4451b7cb][Redirect #donetop][/IfAnchor]
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[HideColumn 66 in #o5a080dd288c3][HideBlock #o9cc73b734d96] [IfAnchor #f2355.01][ShowBlock #o9cc73b734d96][HideBlock #o5a080dd288c3][Redirect #donetop][FillField f2355 with "Yes"][/IfAnchor] [IfAnchor #f2355.02][ShowBlock #o9cc73b734d96][HideBlock #o5a080dd288c3][Redirect #donetop][FillField f2355 with "No"][/IfAnchor]
[HideColumn 66 in #o9cc73b734d96][HideBlock #o92c36475fe45] [IfAnchor #f2357.01][ShowBlock #o92c36475fe45][HideBlock #o9cc73b734d96][Redirect #donetop][FillField f2357 with "Yes"][/IfAnchor] [IfAnchor #f2357.02][ShowBlock #o92c36475fe45][HideBlock #o9cc73b734d96][Redirect #donetop][FillField f2357 with "No"][/IfAnchor]

Conditions

Do you have any of the following conditions? (Select all that apply)
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[HideColumn 66 in #o92c36475fe45][HideBlock #of2e02c6b464a] [SyncFields f2591,f2593,f2595,f2597,f2599,f2601,f2603,f2605,f2607,f2609,f2612,f2614,f2616] [IfField f2591 is unchecked AND f2593 is unchecked AND f2595 is unchecked AND f2597 is unchecked AND f2599 is unchecked AND f2601 is unchecked AND f2603 is unchecked AND f2605 is unchecked AND f2607 is unchecked AND f2609 is unchecked AND f2612 is unchecked AND f2614 is unchecked AND f2616 is unchecked][ShowElement 89 in #o92c36475fe45][HideElement 88 in #o92c36475fe45][/IfField][IfField f2616 is checked][FillField f2591,f2593,f2595,f2597,f2599,f2601,f2603,f2605,f2607,f2609,f2612,f2614 with unchecked][/IfField][IfField f2591 is checked OR f2593 is checked OR f2595 is checked OR f2597 is checked OR f2599 is checked OR f2601 is checked OR f2603 is checked OR f2605 is checked OR f2607 is checked OR f2609 is checked OR f2612 is checked OR f2614 is checked][FillField f2616 with unchecked][/IfField] [IfAnchor #o92c36475fe45.01][ShowBlock #of2e02c6b464a][HideBlock #o92c36475fe45][Redirect #donetop][/IfAnchor]
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[HideColumn 66 in #of2e02c6b464a][HideBlock #o14a7ad89b939,#o0c1c4486c515] [IfAnchor #f2359.01][ShowBlock #o14a7ad89b939][HideBlock #of2e02c6b464a][Redirect #donetop][FillField f2359 with "Yes"][/IfAnchor] [IfAnchor #f2359.02][ShowBlock #o0c1c4486c515][HideBlock #of2e02c6b464a][Redirect #donetop][FillField f2359 with "No"][/IfAnchor]

Conditions

Please describe the type and location
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[HideColumn 66 in #o14a7ad89b939][SyncFields f2361] [IfField f2361 not ''][ShowElement 81 in #o14a7ad89b939][HideElement 82 in #o14a7ad89b939][/IfField] [IfAnchor #f2361.continue][ShowBlock #o0c1c4486c515][HideBlock #o14a7ad89b939][Redirect #donetop][/IfAnchor] [Validate #o14a7ad89b939-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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What other information or questions do you have for the doctor?
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[HideColumn 66 in #o0c1c4486c515][SyncFields f2369][HideBlock #o36050e017fed] [IfField f2369 not ''][ShowElement 81 in #o0c1c4486c515][HideElement 82 in #o0c1c4486c515][/IfField] [IfAnchor #f2369.continue][ShowBlock #o36050e017fed][HideBlock #o0c1c4486c515][Redirect #donetop][/IfAnchor] [Validate #o0c1c4486c515-firstname IBAN “Please enter a valid IBAN” prevent=yes]
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Please attest to the following confirming that all information you have provided to us is true and complete.

I verify that I am the patient and that I have answered the questions asked in this intake form.  I confirm that I have reviewed and understood all the questions asked of me.  I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor.  I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.

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Please read the following information carefully before continuing with this visit. By proceeding, you acknowledge that you understand and agree to the terms below.

This visit is being conducted through telemedicine and will be used to evaluate and treat a skin rash or dermatitis. Because this is a remote encounter, your healthcare provider will rely on the medical history you provide and the quality of the images you upload. High-quality photos are essential for us to make the safest and most accurate assessment possible.

This encounter is intended to diagnose and manage non-emergent skin rashes that may include eczema, contact dermatitis, seborrheic dermatitis, mild fungal infections, or other mild inflammatory skin conditions. Treatment may include prescription medications, non-prescription recommendations, and instructions on skin care, triggers, and follow-up.

Remote evaluation has inherent limitations, and certain conditions cannot be diagnosed or safely managed without an in-person physical exam. Some rashes may require close inspection, palpation, dermoscopy, or additional diagnostic testing (such as a skin scraping, culture, or biopsy) that cannot be performed through telemedicine. If your provider determines that your symptoms, photos, or medical history suggest a more serious condition, you may be advised to seek in-person care.

Telemedicine is not appropriate for severe or rapidly worsening rashes, rashes with systemic illness, life-threatening allergic reactions, or severe drug reactions. Examples include (but are not limited to):
​​​​​​​
  • Rapidly spreading rash with fever or chills
  • Face, lip, or tongue swelling
  • Difficulty breathing or swallowing
  • Blistering over large areas of the body
  • Peeling skin or painful raw areas
  • Rash involving the eyes, mouth, or genitals with severe symptoms
  • Suspected Stevens–Johnson syndrome, toxic epidermal necrolysis, or vasculitis

If you are experiencing any of these symptoms, you should stop this visit and seek emergency medical attention immediately.
Based on your symptoms and photos, your provider may prescribe treatments such as:
 
  • Topical corticosteroids (various potencies depending on the body location)
  • Topical antifungal medications
  • Medicated shampoos
  • Non-steroidal anti-inflammatory skin medications
  • Oral allergy medications

Steroid creams can cause side effects such as skin thinning, discoloration, visible blood vessels, and increased susceptibility to infection especially when used on the face, neck, groin, or for prolonged periods. If a topical steroid is prescribed, it is important to follow the exact instructions provided.

Your responsibilities:

You agree to:
 
  • Provide truthful and complete medical information.
  • Upload clear, high-quality photos of the affected areas.
  • Use all medications exactly as prescribed.
  • Seek in-person care if your condition worsens or does not improve.
  • Seek urgent care or emergency care if you develop severe symptoms.

As with any medical encounter, there are risks, including the possibility of misdiagnosis or delayed diagnosis due to the limitations of telemedicine and image quality. There may also be side effects or allergic reactions to medications. If you experience worsening symptoms or unexpected reactions, you agree to stop the medication and contact a healthcare provider immediately.

Most rashes should show early improvement within 1–2 weeks. If your rash is not improving, is spreading, or new symptoms develop, you may need in-person evaluation. You acknowledge that this telemedicine visit does not replace the need for in-person follow-up when medically necessary.

By continuing, you confirm that you understand the purpose, risks, benefits, and limitations of this telemedicine visit, and you consent to being evaluated and treated remotely. You understand that your provider may advise in-person care if your condition cannot be safely managed through telemedicine.
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Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.

What you were seeking help for:

• Skin Rash

Why this happens

Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.

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