Thank you for visiting us today and we’re sorry to hear about your symptoms. In this intake form, we will ask about your current symptoms and your medical history to guide safe, effective treatment of your symptoms. For any signs of a complicated infection, or if you’ve had antibiotic-resistant infections before, an in-person evaluation is recommended to ensure timely, appropriate care.
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We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.
What was your sex assigned at birth?
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Are you currently pregnant, breastfeeding or planning to become pregnant?
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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy or when breastfeeding. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus. 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.
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[HideColumn 66 in #o0fd35d76fd5f][HideBlock #o1f805a1bb0b7] [IfAnchor #f2331.01][HideBlock #o0fd35d76fd5f][ShowBlock #o1f805a1bb0b7][Redirect #donetop][FillField f2331 with "None"][/IfAnchor][IfAnchor #f2331.02][HideBlock #o0fd35d76fd5f][ShowBlock #o1f805a1bb0b7][Redirect #donetop][FillField f2331 with "One"][/IfAnchor][IfAnchor #f2331.03][HideBlock #o0fd35d76fd5f][ShowBlock #o1f805a1bb0b7][Redirect #donetop][FillField f2331 with "Two"][/IfAnchor][IfAnchor #f2331.04][HideBlock #o0fd35d76fd5f][ShowBlock #o1f805a1bb0b7][Redirect #donetop][FillField f2331 with "Three"][/IfAnchor][IfAnchor #f2331.05][HideBlock #o0fd35d76fd5f][ShowBlock #o1f805a1bb0b7][Redirect #donetop][FillField f2331 with "Four or more infections"][/IfAnchor]
[HideColumn 66 in #o1f805a1bb0b7][HideBlock #o2473b8e12323,#od6f0e92dfe19] [IfAnchor #f2333.01][HideBlock #o1f805a1bb0b7][ShowBlock #o2473b8e12323][Redirect #donetop][FillField f2333 with "Amoxicillin or penicillin"][/IfAnchor][IfAnchor #f2333.02][HideBlock #o1f805a1bb0b7][ShowBlock #o2473b8e12323][Redirect #donetop][FillField f2333 with "Doxycycline"][/IfAnchor][IfAnchor #f2333.03][HideBlock #o1f805a1bb0b7][ShowBlock #o2473b8e12323][Redirect #donetop][FillField f2333 with "Celphalosporins (cefixime, cefpodoxime)"][/IfAnchor][IfAnchor #f2333.04][HideBlock #o1f805a1bb0b7][ShowBlock #o2473b8e12323][Redirect #donetop][FillField f2333 with "Fluoroquinolones (Levofloxacin, moxifloxacin)"][/IfAnchor][IfAnchor #f2333.05][HideBlock #o1f805a1bb0b7][ShowBlock #od6f0e92dfe19][Redirect #donetop][FillField f2333 with "Other"][/IfAnchor]
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[HideColumn 66 in #o9d687e874635][HideBlock #o0ac4abbf86f1] [IfAnchor #f2345.01][HideBlock #o9d687e874635][ShowBlock #o0ac4abbf86f1][Redirect #donetop][FillField f2345 with "Clear"][/IfAnchor][IfAnchor #f2345.02][HideBlock #o9d687e874635][ShowBlock #o0ac4abbf86f1][Redirect #donetop][FillField f2345 with "Cloudy or thick"][/IfAnchor][IfAnchor #f2345.03][HideBlock #o9d687e874635][ShowBlock #o0ac4abbf86f1][Redirect #donetop][FillField f2345 with "Yellow or green"][/IfAnchor][IfAnchor #f2345.04][HideBlock #o9d687e874635][ShowBlock #o0ac4abbf86f1][Redirect #donetop][FillField f2345 with "I don’t have any nasal discharge"][/IfAnchor]
[HideColumn 66 in #o0ac4abbf86f1][HideBlock #o93de2980993f,#o58b3cdfbd7c4] [IfAnchor #f2347.01][HideBlock #o0ac4abbf86f1][ShowBlock #o93de2980993f][Redirect #donetop][FillField f2347 with "Over-the-counter pain relievers or decongestants"][/IfAnchor][IfAnchor #f2347.02][HideBlock #o0ac4abbf86f1][ShowBlock #o93de2980993f][Redirect #donetop][FillField f2347 with "Saline nasal irrigation"][/IfAnchor][IfAnchor #f2347.03][HideBlock #o0ac4abbf86f1][ShowBlock #o93de2980993f][Redirect #donetop][FillField f2347 with "Intranasal steroid spray"][/IfAnchor][IfAnchor #f2347.04][HideBlock #o0ac4abbf86f1][ShowBlock #o93de2980993f][Redirect #donetop][FillField f2347 with "Antibiotics"][/IfAnchor][IfAnchor #f2347.05][HideBlock #o0ac4abbf86f1][ShowBlock #o58b3cdfbd7c4][Redirect #donetop][FillField f2347 with "Other"][/IfAnchor][IfAnchor #f2347.06][HideBlock #o0ac4abbf86f1][ShowBlock #o93de2980993f][Redirect #donetop][FillField f2347 with "I haven’t tried anything yet"][/IfAnchor]
[HideColumn 66 in #o93de2980993f][HideBlock #oc78f79493fb0] [IfAnchor #f2351.01][HideBlock #o93de2980993f][ShowBlock #oc78f79493fb0][Redirect #donetop][FillField f2351 with "Yes"][/IfAnchor][IfAnchor #f2351.02][HideBlock #o93de2980993f][ShowBlock #oc78f79493fb0][Redirect #donetop][FillField f2351 with "No"][/IfAnchor]
[HideColumn 66 in #oc78f79493fb0][HideBlock #o3dcea1811232] [IfAnchor #f2353.01][HideBlock #oc78f79493fb0][ShowBlock #o3dcea1811232][Redirect #donetop][FillField f2353 with "No, I’m not experiencing fevers"][/IfAnchor][IfAnchor #f2353.02][HideBlock #oc78f79493fb0][ShowBlock #o3dcea1811232][Redirect #donetop][FillField f2353 with "Yes, but for less than 24 hours"][/IfAnchor][IfAnchor #f2353.03][HideBlock #oc78f79493fb0][ShowBlock #o3dcea1811232][Redirect #donetop][FillField f2353 with "Yes, for longer than 24 hours"][/IfAnchor]
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[HideColumn 66 in #o97ba5e2e5ae1][HideBlock #o553c3bcf8a79] [IfAnchor #f2357.01][HideBlock #o97ba5e2e5ae1][ShowBlock #o553c3bcf8a79][Redirect #donetop][FillField f2357 with "Immunocompromised condition (eg, diabetes, cancer therapy)"][/IfAnchor][IfAnchor #f2357.02][HideBlock #o97ba5e2e5ae1][ShowBlock #o553c3bcf8a79][Redirect #donetop][FillField f2357 with "Multiple chronic health conditions"][/IfAnchor][IfAnchor #f2357.03][HideBlock #o97ba5e2e5ae1][ShowBlock #o553c3bcf8a79][Redirect #donetop][FillField f2357 with "Difficulty with follow-up or unreliable access to care"][/IfAnchor][IfAnchor #f2357.04][HideBlock #o97ba5e2e5ae1][ShowBlock #o553c3bcf8a79][Redirect #donetop][FillField f2357 with "Known nasal or sinus anatomical issues (eg, deviated septum, polyps)"][/IfAnchor][IfAnchor #f2357.05][HideBlock #o97ba5e2e5ae1][ShowBlock #o553c3bcf8a79][Redirect #donetop][FillField f2357 with "None of these apply to me"][/IfAnchor]
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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.
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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I understand that I am seeking evaluation and treatment for symptoms of sinusitis via a telemedicine encounter rather than an in-person visit. I acknowledge the following:
Nature of Treatment
My healthcare provider will review my symptoms, medical history, and any information I provide to diagnose and treat acute sinusitis. Treatment may include recommendations for over-the-counter medications, saline nasal irrigation, and prescription of intranasal steroids or antibiotics if indicated.
Alternatives:
I understand that I may seek in-person evaluation and treatment at any time, including urgent or emergency care if my condition worsens or if I develop red-flag symptoms (severe eye pain/swelling, vision changes, stiff neck, confusion).
Benefits and Risks:
Patient Responsibilities:
I agree to provide complete and accurate information about my medical history, current symptoms, and any medications or allergies. I will follow the provider’s instructions for treatment and notify them promptly if my symptoms worsen or new symptoms develop.
By proceeding, I confirm that I have read and understood this consent form and voluntarily agree to telemedicine evaluation and treatment for my sinusitis symptoms. I understand that I can withdraw my consent at any time and seek care in person if I prefer
Nature of Treatment
My healthcare provider will review my symptoms, medical history, and any information I provide to diagnose and treat acute sinusitis. Treatment may include recommendations for over-the-counter medications, saline nasal irrigation, and prescription of intranasal steroids or antibiotics if indicated.
Alternatives:
I understand that I may seek in-person evaluation and treatment at any time, including urgent or emergency care if my condition worsens or if I develop red-flag symptoms (severe eye pain/swelling, vision changes, stiff neck, confusion).
Benefits and Risks:
- Most cases of acute sinusitis are viral and improve without antibiotics; symptomatic management carries minimal risk.
- Antibiotic therapy, if prescribed, carries potential side effects (eg, gastrointestinal upset, allergic reaction, antibiotic resistance).
- Saline irrigation and intranasal steroids may cause mild nasal irritation, nose bleeds or discomfort.
- Telemedicine has inherent limitations, including inability to perform a physical exam or obtain imaging immediately.
Patient Responsibilities:
I agree to provide complete and accurate information about my medical history, current symptoms, and any medications or allergies. I will follow the provider’s instructions for treatment and notify them promptly if my symptoms worsen or new symptoms develop.
By proceeding, I confirm that I have read and understood this consent form and voluntarily agree to telemedicine evaluation and treatment for my sinusitis symptoms. I understand that I can withdraw my consent at any time and seek care in person if I prefer
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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:
• Sinusitis
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.
You chose not to proceed with this evaluation. No further action is required.
If you change your mind or need care later, you’re welcome to start a new visit at any time.
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© 2026 OrderlyCares. All Rights reserved
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