RTHM Waitlist

RTHM Waitlist

Please complete the intake survey below to be added to the waitlist. We will contact you with more information.
Name *

First Name Last Name
E-mail *
example@example.com
Address *

Street Address

Street Address Line 2

City State

Zip Code
Country *
Phone Number *

Country Code Area Code Phone Number
Date of birth *

Month Day Year
Date
I am interested in: (Check all that apply)

Telehealth appointments through the RTHM Clinic Ordering new diagnostics available through RTHM Lab Participating in clinical trials associated to my condition Receiving information regarding treatment, diagnostics, and latest research
When do you suspect you first contracted COVID? *

Month Day Year
Date
For how long have you experienced Long COVID symptoms? *

1 - 2 months 2 - 6 months 6 - 12 months More than 12 months
Was your COVID confirmed by a test?

PCR test Rapid antigen test Antibody test T-cell test Imaging (X-ray, CT) Clinician confirmed though no test performed None of the above
Was your COVID confirmed by any of the tests below? (select all that apply)

PCR test Rapid antigen test Antibody test T-cell test Imaging (X-ray, CT) Other
Were you hospitalized with COVID?

Yes No
Did you require any of the following as part of your COVID care? (check all that apply):

Supplemental oxygen ICU level care Non-invasive ventilation (BIPAP, etc.) Intubation (breathing tube) Treatment with dexamethasone Treatment with Remdesivir Treatment with monoclonal antibodies
Did you experience any of the following issues in association with COVID? (check all that apply):

Blood clots (DVT, pulmonary embolism, etc.) Heart attack, heart failure, myocarditis, or pericarditis Renal failure (requiring dialysis) Acute respiratory distress syndrome (ARDS) Guillain-Barré syndrome, Miller Fisher syndrome, transverse myelitis Seizures, coma, stroke, and/or psychosis Other
Do you have a primary care doctor you've seen in the past six months? *

Yes No
Are you already established with any of the following specialists (check all that apply):

Neurologist Rheumatologist Gastroenterologist Cardiologist Pulmonologist Hematologist Pain management & rehabilitation (PM&R) or physiatrist Psychiatrist Mental health therapist Physical therapist Home health Other
Do you have health insurance? *

Yes No
What type of health insurance do/will you have?

Employer-sponsored plan Non-employer plan (individual plan) Kaiser Permanente Medicare Standard Medicare Advantage State insurance VA or TRICARE Other
Are you comfortable having medical conversations in English without a translator?

Yes No
Are you comfortable having medical conversations in English without a translator?

Yes No
Which description below best characterizes your current quality of life?

I am able to carry on normal activity; minor signs or symptoms of disease. I can do normal activities with effort; some signs or symptoms of disease. I can care for myself, but I am unable to carry on normal activity or to do active work. I require occasional assistance, but I am able to care for most of my needs. I require considerable assistance and frequent medical care. I am disabled and require special care and assistance. I am severely disabled; hospitalization is indicated
How much are you currently affected in your everyday life by Long COVID? *

I have no limitations in my everyday life and no symptoms, pain, depression or anxiety. I have negligible limitations in my everyday life as I can perform all usual duties/activities, although I still have persistent symptoms, pain, depression or anxiety. I suffer from limitations in my everyday life as I occasionally need to avoid or reduce usual duties/activities or need to spread these over time due to symptoms, pain, depression or anxiety. I am, however, able to perform all activities without any assistance. I suffer from limitations in my everyday life as I am not able to perform all usual duties/activities due to symptoms, pain, depression or anxiety. I am, however, able to take care of myself without any assistance. I suffer from severe limitations in my everyday life: I am not able to take care of myself and therefore I am dependent on nursing care and/or assistance from another person due to symptoms, pain, depression or anxiety.
How did you become aware of RTHM Clinic? *

Facebook post Instagram post LinkedIn post Reddit post Google search Media article/video Friend Other
Any other details about your case that you wish to provide:
Should be Empty: