New General Reg form/ Version A

Check for Existing Patient
Functional med patient (1=Yes)
Check for site (5= goto) (4=infowars)
Registration came from:
AGE
Current Date*

MonthDayYear
Date
BP/ Heart rate check [30 days earlier]

MonthDayYear
Date
Licensed State
afmc
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.
Are you a new or existing patient?*

new patientexisting patient
Are you experiencing a medical emergency or anything that needs immediate attention from a medical provider?*

yesno
Please go to the nearest ER if you can do so safely, otherwise call an ambulance to take you. We cannot safely evaluate and treat emergencies online and cannot guarantee any immediate medical assessments.*
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.
Are you seeking help for any of these DANGEROUS symptoms that cannot be handled virtually and require in person urgent care?

I HAVE NONE OF THE BELOWRecent onset of any of these:
Severe difficulty waking up; extreme confusion; recurrent fainting, severe vomiting or diarrhea; coughing up blood; vomiting blood; bloody stool; suicidal thoughts; violent thoughts; difficulty breathing; severe shortness of breath; can’t swallow food or water; trama; a possible broken bone; worst headache ever; sudden onset headache; any sudden and severe pain; difficulty speaking; slurred speech; suddenly can’t find words; new face drooping; recent loss of bowel or bladder control; recent loss of ability to move; recent loss of sensation, moderate to the severe chest or upper stomach pain for more than 2 minutes; very unusual stomach pain; eye pain; chang or loss in vision; shingles affecting the eye; unusual or unexplained change or loss of hearing; uncontrolled bleeding; bad burn, facial burn.
The symptoms you selected above indicate you may be experiencing a medical emergency and waiting for an online telemedicine consult may be dangerous. Please consult a doctor in person right away.
What state are you in now?*
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.
Please select the state you are visiting or will be passing through.*
Please enter your zip code to help us select the best pharmacy to send your Rx.*
Please enter your home state zip code to help us select the best pharmacy to send your Rx.*

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

MonthDayYear
Date of Birth
Please recheck your date of birth - it looks like the year was entered wrong making you too old.
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 NameLast Name
Date of birth of parent or legal guardian:*

MonthDayYear
Date of Birth
* 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.
What is your sex?*

femalemale
Are you currently pregnant or plan on becoming pregnant?

currently pregnantmight be pregnantcouldn't possibly be pregnant
Please select the reason you are sure you are not pregnant:

hysterectomytubal ligationbirth controlmenopausenot sexually active within last 30 days
What week of pregnancy are you in now?
Are you currently breastfeeding?

breast feedingnot breast feeding
What is the age in months of the youngest child that is breastfeeding currently?
Which of the following best describes you? Please select all that apply

American Indian or Alaska NativeWhiteBlack or African AmericanAsian IndianChineseFilipinoJapaneseKoreanVietnameseAsianNative HawaiianGuamanian or ChamorroSamoanHispanicPacific IslanderPrefer not to answer
Asian
Pacific Islander
Have you been recently vaccinated or boosted for covid-19?*

yesno
Please enter the date of your latest vaccination:*

MonthDayYear
Date
Which covid-19 vaccination did you get?*
Have you tested positive for COVID-19 since the pandemic began?*

yesno
Please enter the date of your latest positive test result:*

MonthDayYear
Date
Which test was used?*

Rapid antigen testPCR testNot sure
Do you have any changes to report in any of these areas: medications, side effects, medical history, family history, supplements, allergies, alcohol/drug use, diet/exercise, toxin exposures, phone number, email address, or home address?*

yesno
Select the sections that need to be updated:*

medical problemsmedicationsside effectsmedical historyfamily historysupplementsallergiesalcohol/drug usediet/exercisetoxin exposureshome address
Please enter any changes to your medical problems not already reported to us and approximate date of diagnosis. Later please log into Push Health and edit your patient profile to reflect these changes since we do not have access to that.*
Please list any changes to your medications here. Afterwards, please log into Push Health and edit your patient profile as well. Your profile belongs to you, we have no access; keeping your information up to date is crucial to ensure best care.*
Please complete the following for each new side effect and afterwards please also log into Push Health and edit your patient profile as well. Your profile belongs to you, we have no access; keeping your information up to date is crucial to ensure best care.*
Do you now have or have you ever had:*

Liver diseaseKidney diseaseDiabetesHeart DiseaseHypertension treated with medicationHypotension (low blood pressure)None
Do you have any of the following medical problems? Please select all that apply*

AsthmaCancerDiabetesHeart DiseaseHypertension treated with medicationHypotension (low blood pressure)Liver DiseaseKidney diseaseEdema (fluid buildup)None
Type of Cancer*
When approximately were you diagnosed with Asthma?*

MonthDayYear
When approximately were you diagnosed with Cancer?*

MonthDayYear
When approximately were you diagnosed with Diabetes?*

MonthDayYear
When approximately were you diagnosed with Heart disease?*

MonthDayYear
When approximately were you diagnosed with Hypertension?*

MonthDayYear
When approximately were you diagnosed with Hypotension?*

MonthDayYear
When approximately were you diagnosed with Liver disease?*

MonthDayYear
When approximately were you diagnosed with Kidney disease?*

MonthDayYear
When approximately were you diagnosed with Edema?*

MonthDayYear
Do you have any other new medical problems to report?*

yesno
Please enter all other medical problems and approximate date of diagnosis. Later please log into Push Health and edit your patient profile to reflect these changes since we do not have access to that.*
Do you have any other medical problem(s)?*

yesno
Please list your other medical problem(s) and approximate date of diagnosis:*
Did you have any other medical problems in the past that may have resolved and are not listed above?*

yesno
Please enter all past medical problems and and approximate date of diagnosis:*
Do you take any other prescription or over the counter medications?*

yesno
Please enter all active prescription AND over the counter medications (Do not include vitamins and/or supplements), doses and how often you take them if you remember:*
Do you take any supplements, vitamins or herbs?*

yesno
Please enter all supplements, vitamins and/or herbs you take along with doses and instructions if you remember:*
Please enter all new supplements, vitamins and/or herbs you take along with doses and instructions if you remember. Later please log into Push Health and edit your patient profile to reflect these changes since we do not have access to that.*
Please list your previously unreported allergies. Later please log into Push Health and edit your patient profile to reflect these changes since we do not have access to that.*
Do you have any allergies to anything?*

yesno
Please enter any medication, food or environmental allergies along with the reactions:*
Do you drink alcohol, smoke or use any drugs? Please select all that apply*

drink alcoholsmoke tobaccosmoke marijuanachew tobaccovapenone of these
Do you diet or exercise?

dietexerciseactive lifestylenormal healthy lifestyleis sitting exercise?
Since first signing up have you tried any other diets that we don't yet know about?

yesno
Which diet(s):

vegetarianveganpaleoelimination dietother
What diet are you on now?

vegetarianveganpaleoelimination diet
What diets have you tried before?

vegetarianveganpaleoelimination dietother
Tell us your experience with the vegetarian diet, when did you do it and for how long? Why did you stop?
Tell us your experience with vegan dieting, when did you do it and for how long? Why did you stop?
Tell us your experience with the paleo diet, when did you do it and for how long? Why did you stop?
Tell us your experience with elimination diets, what did you eliminate, when did you do it and for how long? Why did you stop?
What diet did you try, how did it go, when were you on it, for how long and why did you stop?
What kind of exercise do you do?

weightscardiostretchingyogawalkinghikingbiking
On average how long and how often do you lift weights?
On average how long and how often do you do cardio?
On average how long and how often do you do yoga?
On average how often and how long do you walk?
On average how often and how long do you hike?
On average how often and how long do you bike?
Tell us briefly about your lifestyle:
Tell us more about your lifestyle:
Do you have any prior or current exposures to toxins that you know of?

asbestossmokedustformaldehydemoldmildewbenzeneammoniachloroformleaduraniummercurynone of these
What kind of dust?
Do you have any previously unreported exposures to toxins?

asbestossmokedustformaldehydemoldmildewbenzeneammoniachloroformleaduraniummercurynone of these
What kind of dust?
Do you know of any medical problems in genetic relatives? (It is not necessary to note medical problems in relatives to whom you are not genetically related, for example a spouse or adopted family member)*

yesno
Please list all of your relatives medical problems:
mother
father
sister(s)
brother(s)
daughter(s)
son(s)
maternal grandmother
maternal grandfather
paternal grandmother
paternal grandfather
other(tell us)
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.
Please provide the best phone number in case Dr. Haider needs to reach you.*

I have a landlineI have a mobile number
Phone (home):*

Area CodePhone Number
Phone (mobile):*

Area CodePhone Number
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: *
Please enter your email address so Dr. Haider can send you a personal invitation to set up your secure chat account:*
example@example.com
Please enter your new address below and later please sign into Push Health and update your patient profile since we do not have access to that.*

Address Line 1

Address Line 2

CityState

Postal / Zip CodeCountry
We are only accepting patients in the United States at this time.
Please enter your receiving address for mail order prescriptions (like ivermectin):*

Address Line 1

Address Line 2

CityState

Postal / Zip CodeCountry
We are only accepting patients in the United States at this time.
Please enter your most CURRENT weight and ACTUAL height, without shoes, for our records and for proper medication dosing (this does NOT need to match what is shown on your ID)*
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.
Do you have any new relevant medical records, images, videos, lab results, or pathology reports that you believe Dr. Haider may require?*

yesno
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.
Please upload your new files here.

Upload Files

Cancelof
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.
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.

Upload Files

Cancelof
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.
In order to legally establish a doctor-patient relationship online, please upload a current photo of yourself to help verify your age and identity.

Upload Files

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

Upload Files

Cancelof
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.
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.

Upload Files

Cancelof
Please upload your parent/guardian's ID. *
Please upload your parent/guardian's ID.
Please upload your parent/guardian's ID.

Upload Files

Cancelof
I am unable to attach files.
Please select the reason(s) you are unable to upload an ID and/or photo:*

I do not have a photo of my ID and/or a selfieThe upload links aren't workingI can't find the photos on my device when I click the upload linkThe upload links won't accept my file types
Please select the reason(s) you are unable to upload your file(s):*

I do not have access to the files right nowThe upload links aren't working for meI can't find the files on my device when I click the upload linkThe upload link won't accept my file types.
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.
Tell us who referred you:

FLCCC AllianceFacebookYouTubeSearch EngineDr. Haider interviewFriend/Family
Location/name of the interview
Please review the information at the following link carefully:
Telemedicine Explanation & Informed Consent
*

By checking the box I am signing my name to signify that I have read, understood and agree to the mygotodoc Telemedicine Consent, and also agree to the Push Health patient portal Terms of Service and Consent to Telehealth and agree to allow Dr Syed Haider and his associates to register me with the Push Health patient portal and set a temporary password for me, which I can later change.
By clicking this checkbox, you indicate that you, as the patient or legal guardian of the patient, agree to allow us to contact you by email, phone or SMS for important updates, including but not limited to changes to our protocols, refill reminders, notice of price changes or new service offerings, and other offers and notifications. Message & date rates may apply. SMS Terms of Service

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.
I hereby authorize mygotodoc, including Dr Syed Haider and his associates, to use telemedicine in the course of my diagnosis and treatment.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Signature
I am unable to draw my signature above.
Signature
By checking this box I certify I am the person mentioned above, or an authorized representative, and I am electronically signing this consent form.
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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