Hawt - Anxiety & Depression App

YOUR INFORMATION ON

Depression-
Anxiety
Treatment

Page 1 of 23

The Basics

This information helps our doctor determine if you're eligible for treatment.

Biological Sex(*)

Male

Female

Please select Male or Female

First Name(*)

Please type your first name.

E-mail(*)

Invalid email address.

Last Name(*)

Please type your last name.

Phone Number(*)

Please enter a valid US phone number. Ex. 123-456-7890

Date of Birth(*)

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Zipcode

Please enter a valid US zip code. Ex. 12356

CONSENT TO SCHEDULE YOUR TELEHEALTH CONSULTATION

PLEASE AGREE TO THE BELOW CONSENT FORM TO SCHEDULE YOUR TELEHEALTH CONSULTATION
Informed Consent for TeleHealth Consultations
"TeleHealth" means that you may be evaluated and treated by a health care provider or specialist from a distant location via electronic communication. Since this may be different than the type of consultation with which you are familiar, it is important you understand and agree to the following statements:
The consulting health care provider will be at a different location from me. Additional medical or registration personnel may also be present in the room with the Provider.
I understand that my voice and image may be recorded in order to assist the medical or registration personnel and I consent to any such audio and video recording.
I understand there are potential risks to this technology, including, but not limited to, interruptions, unauthorized access, technical difficulties, and call termination. I understand there are alternatives and limitations to this type of care. I understand that my health care provider or I can discontinue the telemedicine consultation/visit if it is felt that the videoconferencing connections are not adequate for my situation.
I understand that I may be released before all my medical problems are known or treated and it is my responsibility to make such conditions or symptoms known to the medical personnel as well as to make arrangements for follow-up care.
I understand that payment will be collected at the time of service and cannot be refunded once the consultation has begun.

Authorizations
The undersigned patient, or authorized individual acting on behalf of the patient, understands and agrees as follows: By typing my name below, I am granting permission to all physicians, therapist, laboratories, and any other professionals of HAWT.COM to perform and administer care and treatment of the patient, or designated other qualified health care provider for such services.
Grants permission to release to third party payor(s), Medicare, Medicaid, their representatives and/or physician(s) involved in the patient's care, any information needed in connection with all care rendered to patient.

Financial Responsibility
I and/or my insurance carrier(s) agree to pay, in a timely manner, for health care services provided. I authorize payments directly to Superior Medical Clinics LLC  for all benefits payable. I understand that most private and government insurers do not include coverage for this service as a "Covered Service". I further agree to pay the agreed fee that will be requested at the time of my TeleHealth consultation. I understand that I am responsible for any unpaid bills not covered by Medicaid, Medicare, and any other private insurance company(s).

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(*)

I understand and agree with the statements above.

Please select the checkbox agreeing to treatment consent.

If you have any children, please list their names, ages, and gender in the below box:

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Other than yourself, who currently lives in your residence. If any, please provide their names, gender, age, and your relationship to them.

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In your own words, describe your current problems as you see them:

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How long has this been going on?

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What made you come at this time?(*)

Please indicate your reason for coming now.

What do you hope to gain from this evaluation and/or counseling?

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If you had difficulties in the past, what have you done to cope? Was it helpful?

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Sexual Orientation:

Heterosexual

Homosexual

Bisexual

I chose not to answer

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Please describe any other symptoms or experiences you have had problems with:

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Have you seen a counselor, psychologist, psychiatrist or other mental health professional before?(*)

Yes

Please make a selection. A selection is required to proceed.

If you have even been seen by a professional, please provide, for each, the Name of the therapist, dates of treatment and your reason for seeking help.

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Are you CURRENTLY taking PSYCHIATRIC medication?(*)

Yes

Please make a selection. A selection is required to proceed.

Please list the current medications you are taking, the dosage, and please explain how long have you been taking the medication. Please be sure to explain if taking the medication has been helpful.

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Are you CURRENTLY taking NON-PSYCHIATRIC medication?(*)

Yes

Please make a selection. A selection is required to proceed.

If yes to taking non-psychiatric medication, please list the medication, dosage, and state how long have you been taking it

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Have you been on PSYCHIATRIC medication in the past?(*)

Yes

Please make a selection. A selection is required to proceed.

If yes to have taken psychiatric medication in the past, please list the medication, dosage, state the first and last time you took it, and what effect was the medication on you.

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Have you been hospitalized for psychiatric reasons?

Yes

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If you have been hospitalized for psychiatric reasons, please provide the hospital name dates of hospitalization and reason

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Have you ever attempted suicide?(*)

Yes

Please make a selection. A selection is required to proceed.

If yes to attempting suicide in the past, please describe the event

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Medical History

Are you CURRENTLY under treatment for any medical condition?(*)

Yes

Please make a selection. A selection is required to proceed.

If yes to having current medical condition, please describe your condion

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List any PRIOR illnesses, operations and accidents

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Social History

Have you been married previously?(*)

Yes

Please make a selection. A selection is required to proceed.

If married before, please describe the marriage(s) and duration(s)

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Education

Highest grade level completed:(*)

List any degrees obtained as applicable

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Did you have any disciplinary problems in school?

Yes

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If so, please explain some of the disciplinary issues you had in school.

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Were you considered hyperactive/ADHD in school? (*)

Yes

Please make a selection. A selection is required to proceed.

Is so, please indicate if you were on any medication. Be sure to provide the name of the medication

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What kinds of grades did you get in school?

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If you have ever served in the military, describe briefly your role and duration of service. Please also indicate what type of discharge (separation) did you get if applicable.

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Substance Abuse

ALCOHOL

Do you drink Alcohol?(*)

Yes

Please make a selection. A selection is required to proceed.

If so, please provide the age of first use of alcohol

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How much do you drink?

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How often do you drink?

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Have you ever passed out from drinking? If yes, please indicate how often

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Have you ever blacked out from drinking? If so, please indicate how often

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Have you ever had the “shakes”? If so, please indicate how often

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Have you ever felt you should cut down on your drinking/drug use?

Yes

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Have you ever felt bad or guilty about your drinking/drug use?

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Have people annoyed you by criticizing your drinking/drug use?

Yes

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Have you ever drank/used drugs in the morning to steady your nerves or relieve a hangover?

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Do you use tobacco? If yes, please indicate how often

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Substance Abuse

OTHER DRUGS

Please indicate for each of the following drug, if you have ever used it, what age at first use, time since last use, and approximate use in the last 30 days: Marijuana, Cocaine, Crack, Heroin, Methamphetamine, Ecstasy.

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Is there anything else you would like us to know about you?

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FINAL STEP
Identify Verification
Your doctor needs to verify your identify with a photo of your face and a photo of your government-issued ID. We need a photo of your face to confirm that the government-issued ID is yours.

Upload front and back images of your ID now.
Accepted file formats:
.jpg, .jpeg, .pdf and not more than 500 KB in size for each file.

(*)

You must upload a photo ID to proceed. Use the Add another file button to add an upload option.

HEALTH INSURANCE
We accept ONLY the following insurances. Please select your insurance type to continue. If your insurance type is not listed below, please select $200 to make your consultation payment.

Payment Type(*)

Regular Medicare, United Healthcare, or Tricare

200 - $ 200.00

Please select your type of insurance, or select "I do not an y of this insurance option..." and pay the required $200 consultation fee.

UPLOAD YOUR
HEALTH INSURANCE CARD
Your doctor needs to verify your health insurance. Please upload front and and back copy of your health insurance card now. You will be notified of your co-pay via email if applicable.

Your Total Payment Today

$ 0.00

Upload front and back of your health insurance card now.
Accepted file formats:
.jpg, .jpeg, .pdf and not more than 500 KB in size for each file.

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PAYMENT
Make your consultation payment
We would process your consultation payment to complete the application.

Payment Details

Card Number

Please enter a valid card number

First Name

Please enter cardholder first name

Last Name

Please enter cardholder last name

Card Expiration Month

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Card Expiration Year

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Card Security Code

Enter your card three-digit code

Card Zip Code

Please enter a valid US zip code. Ex. 12356

Please indicate your preferred 1st option date and time to consult with your doctor for this visit:(*)

Please select date and time

Please indicate your preferred 2ndt option date and time to consult with your doctor for this visit if we are unable to schedule your 1st option:(*)

Please select date and time

How may we notify you of a different date and time if the physician is not able to accomodate your two date and time options:(*)

Phone Call

Phone Text

Please select how we may contact you if we are unable to accomodate your selected date and time options.

You have completed your application.
Click submit to submit your application

YOUR INFORMATION ON

Depression-
Anxiety
Treatment

You can call us at

+ (813) 549-7465

US-Licensed Telemedicine Solution

YOUR INFORMATION ON

Depression- Anxiety Treatment

You can call us at

+ (813) 549-7465

US-Licensed Telemedicine Solution

Depression-
Anxiety
Treatment