Please complete the form below prior to scheduling your immune support telehealth visit. Please enable JavaScript in your browser to complete this form.Date of birth *Best phone number *List all of your diagnosed health conditions. *List all over-the-counter and prescription medication you are currently taking. *List all food, drug, and environmental allergies that you have. *Which of the options below most applies to you? *Not currently ill. Looking for immune support.Currently ill and experiencing symptoms.If you are currently ill, please check all of the symptoms you are currently experiencing.Dry coughProductive coughSneezingCongestionShortness of breathBlood in sputum/mucusFatigue/TirednessBody achesFeverSore throatChillsSwollen lymph nodesChest pressureHeadacheNauseaLoss of appetiteDiarrheaNone of the aboveAre you experiencing any other concerns? *Is there anything else you'd like to share? *EmailSubmit