Prevention of COVID-19

Patient Information and History Form. Please Complete The Fields As Indicated (Required fields indicated by “*”, Then SUBMIT

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Date of birth (month/date/year) *

Phone *

Email *

Alternate Email (an alternate email in case you are unable to answer your primary email address) *

Have you completed a COVID-19 vaccination series? *

• Yes
• No

Are you having any of the following? *

• fever between 100 and 102 degrees
• fever above 102 degrees
• cough
• difficulty breathing
• chills
• sore throat
• runny nose
• headache
• muscle ache
• very tired, fatigued
• loss of ability to taste or smell
• none of the above

If you are having any of the above symptoms, for how many days have you been having them? *

• One day
• Two days
• Three days
• Four days
• Five or more days
• I am not having any of these symptoms

If you are having any fever, enter your highest temperature in the past 24 hours, if no fever, enter "none" *

Your pulse/heart rate (for example: 70) *

Your breathing rate per minute (for example: 18) *

Your pulse oximeter oxygen % reading (if you don't have a pulse oximeter, enter "none") (seek emergent medical attention if below 90%) *

Your weight (in pounds) *

Your height ( in feet and inches)(for example, 5' 6") *

List any other current illnesses (enter "none" if none) *

Do you have any of these chronic conditions? *

• diabetes
• chronic lung disease
• chronic heart disease
• heart failure
• heart rhythm disorder/pacemaker
• cancer
• none of the above

List any other chronic conditions (enter "none" if none) *

List all your prescription medications (enter "none" if none) *

Check if you are allergic to any of these: *

• vitamin C
• vitamin D
• zinc
• quercetin
• ivermectin
• hydroxychloroquine
• azithromycin
• doxycycline
• none of the above

If you have had a COVID-19 test, what was the result? *

• no test to date
• negative
• positive
• result not back yet

If you have had a COVID-19 test, what was the date you had the test? (enter "none" if none) *

Are you a member of any of these COVID high risk groups? *

• Black or African-American
• Hispanic or Latino
• Police, Fire, EMS
• Hospital Worker
• None of the above

Requests for medications to reduce the risk of COVID-19 (prevention) will be answered by email by the end of the next business day if possible. If you don't see a response, check your spam folder. We give priority to those needing treatment, by age from the oldest to the youngest, and by high to low risk racial and occupational groups. Do you wish to have medications for prevention of COVID-19? *

• Yes (no charge at this time, offered as a public service))

The chain pharmacies are refusing to fill ivermectin prescriptions. The following pharmacies have such prescriptions. Select one or make your own suggestion if you know they take such prescriptions:

• Savco Pharmacy, 455 O'Connor Drive, Ste. 190,, San Jose, CA, 408-298-6190 (mail delivery available)
• Lauden Pharmacy, 1820 41st Ave., #F, Capitola, CA, 831-462-9880
• Imperial Pharmacy, Imperial Beach, CA (mail delivery available)
• Suggest another pharmacy in "Comments" below

TeleHealth & Follow-Up Authorization: I give permission to this office to treat me by means of telehealth services pursuant to Governor Newsom's Order of April 3, 2020, to communicate with me through the email address provided above, and to contact me by email not more than once per week for a short follow-up inquiry on my prevention and/or treatment program only, no marketing emails. *

• yes

Required HIPPA Privacy Practices Notice *

• yes, I have been shown a copy of this office's HIPPA Privacy Practices Notice

Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D., J.D., CA Medical License #G67169 provides this NOTICE TO CONSUMERS: Medical doctors are licensed and regulated by the Medical Board of California (800) 633-2322 www.mbc.ca.gov. Click "yes" to acknowledge receipt of this legally required notice. *

• yes

Your Questions or Comments, Is There Anything Else You Wish To Mention?

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