Genital Herpes

Do you agree to our telehealth consent and terms and conditions? * This field is required.Please note that you will need to submit this form in order for a provider to review it. If you just curious about the questions, then you do not need to submit the form.

AgreeDisagree

In order to use Choix, you do need to agree to our legal terms. If you want to review them then head over to our legal section or if you have any questions, please send us a note at support@mychoix.co.

What is your age?* This field is required.

In which state do you plan to receive your medical care?* This field is required.Choix only operates in a select number of states. If you state isn't listed then unfortunately we don't provide care there just yet.

Choix can only provide genital herpes care for patients that are seeking medical care within the following states and age groups.

- California, Colorado, Illinois, New Mexico (18 years old or older) and Maine

This unfortunately means that we will not be able to meet your needs at this time. Please follow up with your health care provider.

Has a medical provider ever diagnosed you with genital herpes?* This field is required.

YESNO

Thank you for your interest in Choix. We currently cannot offer treatment for patients who have not been diagnosed with herpes by a medical provider. For your safety, we recommend you seek in person care with a medical provider when you have symptoms of an outbreak.

How were you diagnosed with genital herpes?* This field is required.Please select all that apply.

Physical/Visual Exam

Blood test

Swab taken of herpes sore

I described my symptoms to the medical provider

When were you diagnosed with genital herpes* This field is required.Please list approximate date that a medical provider diagnosed you with herpes.

Which medical conditions apply to you?* This field is required.Please select all that apply.

Taking medicine that can be toxic to the kidney (gentamicin antibiotic, chemotherapy)

History of kidney problems

Seizure or epilepsy

Treatment for cancer with chemotherapy

Organ transplant

HIV

Immune disorders

Inflammatory bowel disease (does not include Inflammatory Bowel Syndrome/IBS)

Long-term use of prednisone / steroids or other immunosuppressive medication

Pregnant

Breastfeeding

None of the above

Thank you for your interest in Choix. We currently cannot offer treatment for patients with certain medical conditions. For your safety, we recommend you seek in person care with a medical provider.

What genital herpes treatments have you used in the past?* This field is required.Please select all that apply.

Over the counter treatments or natural treatments

Prescription creams or gels

Daily pill(s) to prevent outbreaks

Pills taken only as needed for outbreaks

I have never had a prescription for herpes treatment

Which symptoms of genital herpes have you experienced?* This field is required.

Painful sores or blisters on the genitals

Tingling, itching, or burning in area where a sore is about to appear

Other

Since you selected other to the previous question, please provide more details.* This field is required.

How many outbreaks do you normally get in a year if you don’t take medicine?* This field is required.Please select one.

Less than once a year

1-5 times a year

6-9 times per year

10 or more times per year

I’m taking medicine regularly to prevent breakouts

And we have reached the halfway point. 😎 Just a few more questions to go.

Please list any allergies or negative side effects you have to medications or substances.* This field is required.List medication name, dose, and describe side effects and or allergy symptoms you experienced.

Please list any past or current medical conditions.* This field is required.For example, history of migraine headaches, high blood pressure, kidney disease, etc

Are you currently taking any other prescription medicines for other medical conditions? * This field is required.Please also include any over-the-counter medications and herbal dietary supplements that you are taking.

YESNO

Please enter the medication name(s) and dosage(s).* This field is required.

Are you currently experiencing any of the following symptoms?* This field is required.Please select all that apply.

Skin rash or blisters that are NOT located in the lips, mouth, genitals, groin, thighs, or back

Severe neck pain with sensitivity to light or sound

Severe headache including pain spreading to the front of your head, eye pain, or ear pain

Problems with vision, including double vision or difficulty focusing

Blisters or sores on around your eyes, eye pain, eyelid swelling or discharge

Confusion

Difficulty with lifting up an arm or leg

Breathing problems, including shortness of breath or wheezing

Chest pain

Painful swallowing

Dizziness

Producing low amounts or no urine

Vomiting

Fever

Painless sores, especially on the hands or genitals

Other

None of the above

Since you selected Other to the previous question, please provide more details.* This field is required.

Were you referred by your healthcare provider for treatment with Choix?* This field is required.

YESNO

Please enter your providers and contact information.* This field is required.

Please choose your medication plan* This field is required.

I would like to take pills daily to prevent outbreaks.

I only want to take pills when I feel an outbreak coming.

How would you like to pay for your treatment?* This field is required.Out of pocket, $10 - $19 for 30 day supply. You will be able to select the brand on the next screen.

Out of pocketInsurance

Which brand would you like to use daily?* This field is required.

Acyclovir 400 mg twice daily ($10/month)

Valacyclovir 500 mg once daily ($12/month)

Other

Which brand would you like to use as needed?* This field is required.

Acyclovir 800 mg three times daily for two days ($10 for 30 tablets)

Valacyclovir 500 mg twice daily for three days ($12 for 30 tablets)

Valacyclovir 1000mg once daily for five days ($19 for 30 tablets)

Other

Since you selected other, which brand would you like?* This field is required.

Do you have a preferred brand/dose?* This field is required.

YesNo Preferred Brand

What is your preferred brand and dose?* This field is required.

What is the name and address of your preferred pharmacy?* This field is required.

My Products* This field is required.

My Bag

HSV Consultation
$20.00+Edit
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