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  • 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.

  • 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.

  • We hope you are feeling better soon and come back to discuss your health with us after you get the emergency care you need for this illness.

  • Dr. Haider is not currently licensed to see patients in Arizona.

  • Dr. Haider's COVID waiver in {state} has expired, and he is awaiting his permanent license. Meanwhile, just because you live in {state} doesn't mean you can't get a Rx filled. When he "sees" you and writes your Rx, as long as you are in one of the states where he has a license, he can legally write it and even send it to your local pharmacy.

    We don't need to see proof of travel, as many people have asked, and your word is sufficient! All you have to do is tell us which state you'll be visiting or passing through below.

  • 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.

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  • Please recheck your date of birth - it looks like the year was entered wrong making you too old.

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  • * Note: You will be asked to furnish IDs and selfies for both yourself and the minor you are registering.

  • 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.

  • In order to offer medical advice, treatment and other patient services online we need to register you as a patient and get your medical history and confirm your identity, same as in any on-the-ground clinic.



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  • Please list all of your relatives medical problems:

  • Please provide the best phone number in case Dr. Haider needs to reach you. *
    The majority of pharmacies use text messages to communicate with our patients; if possible, please add your mobile phone number.

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  • Please enter your email address so Dr. Haider can send you a personal invitation to set up your secure chat account: *

  • Please confirm your best email address: *

  • We are only accepting patients in the United States at this time.

  • We are only accepting patients in the United States at this time.

  • Your BMI is {bmiCalculator}. A BMI of 18.5 or less usually means you are underweight and is a risk factor for anemia, depression, immune deficiencies, bone problems and tooth decay.

  • Your BMI is {bmiCalculator}. A BMI between 18.5 - 24.9 usually means you have a normal weight.

  • Your BMI is {bmiCalculator}. A BMI between 25.0 - 29.9 usually means you are overweight, which increases your risk of heart disease, diabetes, high blood pressure, gall bladder disease, and some cancers.

  • Your BMI is {bmiCalculator}. A BMI over 30 usually means you are obese, which increases your risk of heart disease, diabetes, high blood pressure, gall bladder disease, and some cancers.

  • Please upload your new files here.
    You can also do this later via the doctor's encrypted and secure chat.
    We respect your privacy. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.

  • Upload Files
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  • Please upload any relevant medical records, images, videos, lab results, or pathology reports that you believe Dr. Haider may require.
    You can also do this later via the doctor's encrypted and secure chat.
    We respect your privacy. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.

  • Upload Files
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  • In order to legally establish a doctor-patient relationship online, please upload a current photo of yourself to help verify your age and identity. *
    We deeply respect your privacy and wouldn’t ask except that it’s required by law (have to weed out any little kids trying to trick us!). Please upload a photo of you alone (aka a selfie); do not include anyone else in the image. If you send us a photo of you with your kids or your wife/husband, we will have to ask you to send us a new photo. We never share your files with anyone. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.

  • In order to legally establish a doctor-patient relationship online, please upload a current photo of yourself to help verify your age and identity.
    We deeply respect your privacy and wouldn’t ask except that it’s required by law (have to weed out any little kids trying to trick us!). Please upload a photo of you alone (aka a selfie); do not include anyone else in the image. If you send us a photo of you with your kids or your wife/husband, we will have to ask you to send us a new photo. We never share your files with anyone. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.

  • Upload Files
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  • Please upload a recent photo of yourself taken with your parent/guardian (less than 60 days old). *

  • Please upload a recent photo of yourself taken with your parent/guardian (less than 60 days old).

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  • To match the photo of yourself please upload a picture of your photo ID with your name and date of birth. Our systems are designed to protect you from identity theft, so you can hide your license number and any other sensitive information if you want to. Your photo, name, and date of birth are the ONLY fields that must be visible on the picture. Please double-check that the photo isn't blurry. *
    Using your phone's camera or scanning an image of your ID is usually preferable; however, please avoid using a webcam because the image quality will prevent you from seeing the text on your ID.

    This is in order to protect you from someone requesting meds in your name and to protect us from treating the wrong person. I drop this in our encrypted vault and never share your photos or data with anyone.

  • To match the photo of yourself please upload a picture of your photo ID with your name and date of birth. Our systems are designed to protect you from identity theft, so you can hide your license number and any other sensitive information if you want to. Your photo, name, and date of birth are the ONLY fields that must be visible on the picture. Please double-check that the photo isn't blurry.
    Using your phone's camera or scanning an image of your ID is usually preferable; however, please avoid using a webcam because the image quality will prevent you from seeing the text on your ID.

    This is in order to protect you from someone requesting meds in your name and to protect us from treating the wrong person. I drop this in our encrypted vault and never share your photos or data with anyone.

  • Upload Files
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  • Please upload your parent/guardian's ID. *

  • Please upload your parent/guardian's ID.

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  • Once you complete registration, we will process your intake form and email you your temporary login and password. You will then upload your ID and selfie through our secure patient portal. We will not process any requests until we have both of them.

    To speed up the process, you can also email the required images to intake@drsyedhaider.com.


  • Please review the information at the following link carefully:
    Telemedicine Explanation & Informed Consent

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  • After clicking COMPLETE REGISTRATION, your registration will be completed and you will be redirected to our SERVICE FORM where you will be able to complete your requests.

    You will receive an email from Dr. Haider within 12-24 hours with your login information for our patient portal, where you will be able to ask questions and message with our medical team completely free.

  • After clicking UPDATE REGISTRATION, you will be redirected to our SERVICE FORM where you will be able to complete your service requests.

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