Hawt - Sick Visit App

YOUR INFORMATION ON

Online Visit

Page 1 of 20

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(*)

Invalid Input

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).

Invalid Input

I understand and agree with the statements above.

Please select the checkbox agreeing to treatment consent.

Surgeries: List Year, Reason and Hospital for each, or just type N/A if not applicable

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Other Hospitalization: List Year, Reason and Hospital for each, or just type N/A if not applicable

Invalid Input

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers. Please include the name of the drug, strength, and frequency taken

Invalid Input

Allergies to medications. Please include the name of the drug and the reaction you had.

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FAMILY HEALTH HISTORY

Father's Age:

Invalid Input

Father's Significant Health Problems:

Invalid Input

Mother's Age:

Invalid Input

Mother's Significant Health Problems:

Invalid Input

Do you have any sibling?(*)

Yes

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

If yes, list number of siblings. Indicate whether male or female, age, and any significant health problems associated

Invalid Input

Do you have any children?(*)

Yes

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

If yes, list number of children. Indicate whether male or female, age, and any significant health problems associated

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Grand Father's Age:
(Maternal)

Invalid Input

Grand Father Significant Health Problems: (Maternal)

Invalid Input

GrandMother's Age:
(Maternal)

Invalid Input

Grand Mother Significant Health Problems: (Maternal)

Invalid Input

Grand Father's Age:
(Paternal)

Invalid Input

Grand Father Significant Health Problems: (Paternal)

Invalid Input

GrandMother's Age:
(Paternal)

Invalid Input

Grand Mother Significant Health Problems: (Paternal)

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Women Only

Please complete the below section of you are a woman. If you are man, please click next until you get to the section titled "Men Only".

Age at onset of menstruation

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Date of last menstruation

Invalid Input

Period days? (Ex. Period every 28 days)

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Heavy periods, irregularity, spotting, pain, or discharge?

Yes

Invalid Input

Number of Pregnancies

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Number of live births

Invalid Input

Men Only

Please complete the below section of you are a man.

Do you usually get up to urinate during the night?

Yes

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

If you urinate nightly, how many times

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Do you feel pain or burning with urination?

Yes

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

Any blood in your urine?

Yes

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

Has the force of your urination decreased?

Yes

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

Have you had any kidney, bladder, or prostate infections within the last 12 months?

Yes

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

Do you have any problems emptying your bladder completely?

Yes

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

Any difficulty with erection or ejaculation?

Yes

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

Any testicle pain or swelling?

Yes

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Date of last prostate and rectal exam?

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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 $30 to make your consultation payment.

Payment Type(*)

Regular Medicare, United Healthcare, or Tricare

30 - $ 30.00

Please select your type of insurance, or select "I do not an y of this insurance option..." and pay the required $30 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

Invalid Input

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

Online Visit

You can call us at

+ (813) 549-7465

US-Licensed Telemedicine Solution