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Registration came from:
Acute/Long check
AGE
Current Date *

Month Day Year
Date
Licensed State
This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.
How can we help you today?
Please choose: *

1-on-1 consultation with Dr. Haider ($599, video or phone, 50 minutes, including any prescriptions you need written) One or more of our Preparedness Protocols (Emergency Antibiotics, 1 Month Backup Supply, COVID Prevention & Treatment & COVID Long Haul Syndrome)
In order to better prepare Dr. Haider for your visit, which, if any, of the following protocols are you interested in? *
Which Preparedness Protocol(s) are you interested in? Please select one or more: *
Which Preparedness Protocol(s) are you interested in? *

Emergency Antibiotic Meds
Antibiotics to store in case of disaster, bioterror attack, supply chain disruption, etc. Includes: amoxicillin/clavulanate, azithromycin, cephalexin, ciprofloxacin, doxycycline, and metronidazole. *
Backup Supply Meds
A 6 week supply of your regular daily meds to keep in storage for disaster, supply chain disruption, or when otherwise unable to get your regular refills on time. No controlled substances like narcotics. *
COVID Prevention & Treatment Meds
Our safe and effective multi-drug protocols for prophylaxis and treatment, to have on hand for prevention or to take on day 1 of symptoms. *
COVID Long Haul Syndrome Meds
Our multi-drug protocol to have on hand in case you develop symptoms of Long COVID. Studies estimate between 30-80% of all people infected, even asymptomatically, will end up developing Long COVID, with symptoms that often appear months later and last a year or more. *
I'd like to consult with Dr. Haider about something unrelated to the above 4 options.
If you don't mind, briefly describe the issue(s) you'd like to discuss. If you prefer, it's ok to leave this field blank.
* Which specific medications you receive will depend on your medical history and current medications.
Doctor's Fee ($): *
The doctor’s fee does not include the price of the medications, which you will pay directly to the pharmacy.
Doctor's Fee
I just want to ask questions and don't want to be charged anything yet. I can't afford the doctor's fee and would like a discount.
We provide asynchronous medical chat with our medical team absolutely free. You may register and ask any questions you may have about health and medical issues. Our service is not meant to replace your PCP and is to be considered informational rather than medical advice, which should always be solicited from a physician in person or in a scheduled phone or video visit.
We aim to make our service affordable and available to everyone, regardless of ability to pay. After completing registration, you will be sent log in instructions for our patient portal. Once you log in, please send a message to the team letting them know what you can afford to pay, if anything, for the doctor's fee. If you cannot afford to pay at all, you will still have to pay the out-of-pocket cost of the meds to the pharmacy.
FYI: At any time, you may use the 'Save' button to save your progress and fill in the registration form later. This is especially useful if your time is limited or you don't have all the required information or paperwork in front of you now.

Clicking the 'Save' button will trigger a pop-up window where you can create a Jotform account (our HIPAA compliant form provider) using Google, Facebook, or email. Signing up for a Jotform account is free and only necessary if you wish to save your form as a draft and receive an email with a link to continue your form at a later date. You do not need to save in order to continue.

This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.
You selected our COVID Prevention & Treatment Meds. Do you have symptoms now? *

Yes, I am sick right now and I want medication to treat an active COVID-19 infection. No, I want to have medication on hand to prevent or treat COVID-19 just in case I develop symptoms.
You selected the COVID Long Haul Syndrome Meds. Do you have symptoms now? *

Yes, I am sick right now and I want medication to treat a suspected case of COVID Long Haul Syndrome. No, I want to have medication on hand to prevent or treat COVID-19 just in case I develop symptoms.
You selected both our COVID Prevention & Treatment Meds & COVID Long Haul Syndrome Meds. Do you have symptoms now? *

Yes, I am sick right now and I want medication to treat an active COVID-19 infection. Yes, I am sick right now and I want medication to treat a suspected case of COVID Long Haul Syndrome. No, I want to have medication on hand to prevent or treat COVID-19 or Long Haul Syndrome just in case I develop symptoms.
Acute Protocol

*We send some prescriptions to mail-order pharmacies that don’t price gouge and are free from corporate pressure. This allows us to best serve patients who want these medications on hand in case of infection, but is not ideal for someone who needs medication today.

If we are your best option for obtaining the treatment you need, please proceed by filling out the intake forms and we will prioritize your registration. Please be sure to complete all registration requirements (upload or email us your ID & selfie, for example) to ensure nothing slows down your prescription.

By selecting the Acute Protocol, you will receive (2) prescriptions: the first with medications that regular pharmacies either don't carry or often refuse to fill, and the second with everything else. The first prescription will go to a low-cost mail-order compounding pharmacy and ship to your door. The second prescription will go to your local pharmacy for speed and convenience and so you have the option of using insurance.

*Exactly which medications you are prescribed will vary depending on your medical history and current medications.
Prevention & Treatment Meds

You will receive two prescriptions: the first with medications for prevention that regular pharmacies often refuse to fill, and the second with everything else.

Some patients only want the Prevention medications, but we write both prescriptions for everyone. This is so all of our patients can be best prepared to begin treatment fast in case they get sick. And so you don’t have to pay another consultation fee if you do end up getting sick.

You do not have to fill the second prescription. Many patients notify the pharmacy not to fill the second Rx and choose to keep it on hand to fill at the first sign of symptoms. Patients also have the freedom to ask their pharmacy to delete one or more meds from any prescription if they are sure they never want to use them.

The first prescription will go to a low-cost mail-order compounding pharmacy and ship directly to your door. We send these off-label prescriptions to reliable, independent pharmacies that don’t price gouge and are free from corporate pressure. The second prescription will go to your local pharmacy for your convenience and allow you the option of using insurance.

The Prevention Protocol dosages are lower than the dosages in case of infection. You will receive both dosage instructions.

*Exactly which medications you are prescribed will vary depending on your medical history and current medications
COVID Long Haul Syndrome Meds

*We send some prescriptions to mail-order pharmacies that don’t price gouge and are free from corporate pressure. This allows us to best serve patients who want these medications on hand in case of infection, but is not ideal for someone who needs medication today.

If we are your best option for obtaining the treatment you need, please proceed by filling out the intake forms and we will prioritize your registration. Please be sure to complete all registration requirements (upload or email us your ID & selfie, for example) to ensure nothing slows down your prescription.

You will receive two prescriptions: the first with medications that regular pharmacies either don't carry or often refuse to fill, and the second with everything else.

The first prescription will go to a low-cost mail-order compounding pharmacy and be shipped directly to your door. The second prescription will go to your local pharmacy for your convenience and so you have the option of using insurance.
You will receive two prescriptions: the first with medications that regular pharmacies either don’t carry (the correct low dosage of naltrexone) or often refuse to fill (ivermectin, hydroxychloroquine)*, and the second with everything else. The first Rx will be sent to a low-cost mail-order compounding pharmacy and shipped directly to your door. In our extensive experience, insurance will not cover the medications in the first Rx. The second prescription will go to your local pharmacy for speed and convenience and so you have the option of using insurance.
COVID Prevention & Treatment Meds + COVID Long Haul Syndrome Meds

You will receive two prescriptions: the first with medications that regular pharmacies either don't carry or often refuse to fill, and the second with everything else.

The first prescription will go to a low-cost mail-order compounding pharmacy and be shipped directly to your door. We send these off-label prescriptions to reliable, independent pharmacies that don’t price gouge and are free from corporate pressure. The second prescription will go to your local pharmacy for speed and convenience and so you have the option of using insurance.

The Prevention Protocol dosages are lower than the dosages in case of infection. You will receive both dosage instructions.

*Exactly which medications you are prescribed will vary depending on your medical history and current medications.

This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.
Our service does not replace your primary care provider. In order to use mygotodoc, you should have had a medical exam at some point in the last 2 years. In order to utilize our medication refill service (Backup Supply Medkit) you should have an ongoing relationship with a prescribing doctor, or be between prescribing providers, with no more than 6 months since your last visit. *

I have a prescribing doctor who is monitoring my regular medication use. I lost my prescribing physician in the last 6 months and haven't found a new one yet. It's been more than 6 months since I had a regular prescribing doctor.
Since you do not have a regular physician monitoring use of your regular ongoing meds we cannot prescribe refills at this time. Please go to an urgent care to get any necessary refills and establish care with a primary doctor before requesting the emergency refill service.

This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.
Please enter your first and last name as it appears on your ID or DL: *

First Name Last Name
Please enter your date of birth: MM/DD/YYYY *

Month Day Year
Date of Birth
Minors may not register on their own. The parent or legal guardian of a minor must register first so that they can give consent for the minor to receive medical treatment. If you are the parent or legal guardian, and you have already registered with us, you can add a child or underage family member to your account inside the patient portal. If you are the parent or legal guardian and you are not yet registered, you may do so now. *
Name of parent or legal guardian: *

First Name Last Name
Date of birth of parent or legal guardian: *

Month Day Year
Date of Birth
* Note: You will be asked to furnish IDs and selfies for both yourself and the minor you are registering.
Please be aware that patients 55 or over have an increased risk of liver injury from ciprofloxacin, which is one of the medications in Emergency Antibiotics Medkit. *
Given your age, Dr. Haider usually recommends an extended high-risk protocol which includes dutasteride and spironolactone (for those patients who are not already on them and don't have any other contraindications), which are thought to help with acute and long COVID, especially in higher-risk men, but also in higher-risk women. Dutasteride is commonly used for men's enlarged prostate and hair loss, and spironolactone is frequently used in both sexes for high blood pressure or as a water pill, and in women for acne.

Both are androgen blockers that can interfere with fetal development, so should not be handled by women of childbearing age (unless they are on strict birth control or otherwise certain they are not and cannot get pregnant), should any women of that description be in the household.

Spironolactone is a potassium-sparing diuretic (water pill), which means that it may raise your body's potassium levels. If you do not take a potassium supplement and you have normal functioning kidneys, then your body can usually handle this and remove any excess potassium. However, if you do take potassium supplementation (often recommended to patients who have chronically low levels due to other diuretics/water pills), and/or if you have low kidney function, then you may develop excessively high levels of potassium when you add spironolactone, which can be dangerous and cause heart arrhythmias in rare cases. Therefore, it is always recommended to get potassium levels checked a week after starting on spironolactone.

If you would like Dr. Haider to consider one or both of these meds for your protocol in case of developing an acute COVID infection, let us know that you have read the above and would like them added to your prescriptions. *
Warning for Dutasteride and Spironolactone: *

I acknowledge the warning Please do not prescribe