Naltrexone Consultation Form

1
Legal Name* This field is required.Please provide you legal name. This is the name we'll use when submitting your prescription, so please make sure it matches the pharmacy's records.
First Name
Middle Name
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2
Gender* This field is required.
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3
Address* This field is required.
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4
Email* This field is required.
example@example.com
5
Phone Number* This field is required.
Please enter a valid phone number.
6
Date of Birth* This field is required.
Date
Month
Day
Year
7
Please enter your height and weight.* This field is required.
8
Please list any drug allergies:If you do not have any drug allergies, you can write "NKDA."
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9
Do you have any medical or psychiatric conditions?Please provide any additional information about your medical history that may be useful to the doctor. If you don't have any, you can simply write "N/A."
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10
Do you have any past surgical history?* This field is required.Please include any details on the next slide.
YESNO
11
Please provide details about your prior operations:
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12
Do you take any medication?* This field is required.This includes any over-the-counter medication and supplements, vitamins, herbal remedies and birth control.
YESNO
13
What medications do you take?Please include the name, strength, and frequency.
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Ok
14
Have you taken Naltrexone before?* This field is required.
YESNO
15
Do you currently take any opioids? This include both legal opioids like OxyContin, and illegal opioids like heroin.* This field is required.It's important patients on Naltrexone DO NOT take any opioid medications. Doing so can cause precipitated withdrawal, a condition that causes one's body to react strongly and quickly, leading to symptoms like muscle pain, restlessness, and upset stomach.
YESNO
16
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 that: 1) I do not currently take any opioids, legal or illegal. 2) I agree not to take any opioids during my treatment. 3) I further agree to notify all my future providers of my treatment with naltrexone.* This field is required.
I agree
17
How often do you exercise per week?
Never
1-2 days per week
3-4 days per week
5+ days per week
18
How much alcohol do you consume in a typical day?
I don't drink
1-2 glasses/day
3-4 glasses/day
5-6 glasses/day
7+ glasses/day
19
How often do you consume caffeine?
I don't consume caffeine
1-2 cups/day
3-4 cups/day
5+ cups/day
20
Do you smoke tobacco products (excluding e-cigarettes)?
No
0-1 pack/day
1-2 packs/day
2+ packs/day
21
How often do you have a drink containing alcohol?* This field is required.
Never
Monthly or less
2 to 4 times a month
2 to 3 times a week
4 or more times a week
22
How many drinks containing alcohol do you have on a typical day when you are drinking?* This field is required.
1 or 2
3 or 4
5 or 6
7, 8, or 9
10 or more
23
How often do you have six or more drinks on one occasion?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
24
How often during the last year have you found that you were not able to stop drinking once you had started?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
25
How often during the last year have you failed to do what was normally expected from you because of drinking?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
26
How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
27
How often during the last year have you had a feeling of guilt or remorse after drinking?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
28
How often during the last year have you been unable to remember what happened the night before because you had been drinking?* This field is required.
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
29
Have you or someone else been injured as a result of your drinking?* This field is required.
No
Yes, but not in the last year
Yes, during the last year
30
Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down?* This field is required.
No
Yes, but not in the last year
Yes, during the last year
31
Do you have insurance?
YESNO
32
Would you like us to submit your prescription to DiRx, an online mail-order pharmacy? Your prescription will cost $30/month, including shipping.
YESNO
33
If you would like us to submit an itemized bill to your insurance company, please upload the front and back of your insurance card. While we cannot guarantee your insurance company will reimburse you, there is no additional cost and it may count towards your out-of-network deductible. If you are not interested, simply hit "Next."
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34
Pharmacy Name
35
Pharmacy Address
Street Address
Street Address Line 2
City
State / Province
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Please Select
Please Select
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Afghanistan
Albania
Algeria
American Samoa
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Angola
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China
Christmas Island
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Croatia
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Malta
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Niue
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Northern Mariana
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36
Pharmacy Phone Number
Please enter a valid phone number.
37
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.* This field is required.
I agree
38
Terms and Conditions* This field is required.
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Privacy Policy* This field is required.
40
Telehealth Policy* This field is required.
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Consent to Treat* This field is required.
42
How did you find out about us? (Google, Physician Referral, Instagram, Facebook, Friend, etc.)
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43
Alcohol Use Disorder Subscriptions
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Monthly Naltrexone Subscription
Features of the Monthly Subscription: 30-day Naltrexone Prescription, automatic refills, ask your Doctor questions via our Patient Portal, 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 dirxhealth.com to get Naltrexone for $30/month. A phone or video visit may be required based on state regulation. Your subscription will renew monthly at $49/month. To cancel, email naltrexone@healthcareintermediaries.com.
$49.00 for each month
SUBSCRIBE
Three Month Naltrexone Subscription
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.
$139.00 for each three months
SUBSCRIBE
Total cost $0.00
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Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
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Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
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Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
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Netherlands
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New Caledonia
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Niue
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Saint Barthelemy
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South Africa
South Ossetia
South Sudan
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Sri Lanka
Sudan
Suriname
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eSwatini
Sweden
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Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
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Turks and Caicos Islands
Tuvalu
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Other
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