Healthcare Intermediaries Naltrexone Form

Healthcare Intermediaries - Naltrexone Consultation
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Gender*
Address
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Patient Height (in's)*
Patient Weight (lbs)*
Patient E-Mail*
Reason for seeing the doctor:

Alcoholism / Naltrexone Consultation
Patient Medical History
Please list any drug allergies*
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Please list any Operations
Please list your Current Medications (Include Dosage, and Frequency)
Do you take any opioids (legal or illegal)? These include prescription medications such as Vicodin, OxyContin, and Percocet. They also include street drugs like heroin and fentanyl. It is very important you do not take Naltrexone with opioids as it can cause Precipitated Withdrawal.*
IT IS VERY IMPORTANT PATIENTS DO NOT TAKE NALTREXONE AND AN OPIOIDS CONCURRENTLY. TAKING BOTH MEDICATIONS CAN CAUSE OPIOID WITHDRAWAL. BY SELECTING THE BUTTON BELOW, I AGREE I DO NOT CURRENTLY TAKE ANY OPIOIDS, LEGAL OR ILLEGAL, AND AGREE NOT TO DURING MY TREATMENT. I FURTHER AGREE TO NOTIFY ALL MY FUTURE PROVIDERS OF MY TREATMENT WITH NALTREXONE.*

I HAVE READ AND FULLY ACCEPT THESE TERMS
Healthy & Unhealthy Habits
Exercise*

Never1-2 days3-4 days5+ days
Eating following a diet*

I have a loose dietI have a strict dietI don't have a diet plan
Alcohol Consumption*

I don't drink1-2 glasses/day3-4 glasses/day5+ glasses/day
Caffeine Consumption*

I don't use caffeine1-2 cups/day3-4 cups/day5+ cups/day
Do you smoke?*

No0-1 pack/day1-2 packs/day2+ packs/day
Include other comments regarding your Medical History
Pharmacy Information

Which pharmacy should we send your prescriptions to?
Pharmacy Name*
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number (optional)

Area CodePhone Number
Pharmacy Fax (optional)

Area CodePhone Number
Alcohol Assessment (AUDIT)
How often do you have a drink containing alcohol?*

Never [Skip to Qs 9-10]Monthly or less2 to 4 times a month2 to 3 times a week4 or more times a week
How many drinks containing alcohol do you have on a typical day when you are drinking?*

1 or 23 or 45 or 67, 8, or 910 or more
How often do you have six or more drinks on one occasion?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you found that you were not able to stop drinking once you had started?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you failed to do what was normally expected from you because of drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you had a feeling of guilt or remorse after drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
How often during the last year have you been unable to remember what happened the night before because you had been drinking?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily
Have you or someone else been injured as a result of your drinking?*

NoYes, but not in the last yearYes, during the last year
Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?*

NoYes, but not in the last yearYes, during the last year
Please give us any more information about your alcohol use that you think may be useful. Please indicate whether you've used Naltrexone before.
Lab Tests
Do you want to receive optional blood work every month to monitor your liver function? We don't charge any additional fees for ordering the test, however, your insurance may. Many patients pay $0 for labs, and most pay less than $15. All labs are submitted to LabCorp unless specified elsewhere.

YesNo
Disclaimers
By clicking "I agree," I agree and understand the following terms. I understand Healthcare Intermediaries, LLC is an intermediary between practitioners and patients; Healthcare Intermediaries, LLC assists in connecting practitioners to patients to provide medical services. I agree to hold Healthcare Intermediaries, LLC harmless from and against any and all claims, damages, costs and expenses, including attorneys' fees, arising from or related to your use of our Company or any Contracts or Services you purchase through it. This release include any and all actions or inactions taken by any affiliated Healthcare Practitioners.*

I agree
I have read and agree to the full Terms and Conditions of Healthcare Intermediaries, LLC. They can be found at https://getsuboxone.com/terms-and-conditions/*

I agree
I have read and agree to the Consent to Telehealth Agreement. They can be found at https://getsuboxone.com/consent-to-telehealth/*

I agree
You are currently set to receive text messages for appointment reminders and information about your health care treatment. If you wish to decline receiving all text messages from Healthcare Intermediaries LLC click here.*

I agree to receiving text messages about my care. SMS allows you to receive faster care by providing an easy way to get in-touch with you . You may opt-out anytime by texting "STOP" to 800-771-8770.OPT-OUT
How did you find out about us? (Google, Physician Referral, Instagram, Facebook, Friend, etc.)
Payment
How do you prefer to pay?*

PayPalVenmo BusinessCheck

Alcohol Use Disorder Consultations*

Naltrexone Monthly Subscription($49.00 for each month)

Features of the Monthly Subscription: 30-day Naltrexone Prescription, automatic refills, ask your Doctor questions via our Patient Portal, 24-Hour Provider Response time, and the ability to cancel at anytime. You'll be given a full refund if you are not prescribed Naltrexone. PLEASE NOTE THE CONSULTATION DOES NOT INCLUDE THE PRICE OF MEDICATION. You will need to pay for the actual medication at the pharmacy. If you do not have insurance, please use dirx.com to get Naltrexone for $30/month. A phone or video visit may be required based on state regulation.

3-Month Naltrexone Prescription($139.00 for each three months)

Purchase a 3-month subscription of Naltrexone at a discounted price! Same rules and conditions apply as the $49/month subscription. Subscription will renew every three months at $139.

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

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Healthcare Intermediaries - Naltrexone Consultation

Patient Medical History

Healthy & Unhealthy Habits

Pharmacy Information

Alcohol Assessment (AUDIT)

Lab Tests

Disclaimers

Payment