Prevention of COVID-19

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

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Your sex
Have you completed an initial COVID-19 vaccination series (two shots)?

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

Do you have any of these chronic conditions?
Check if you are allergic to any of these:
If you have had a COVID-19 test, what was the result?
Are you a member of any of these COVID high risk groups?
The chain pharmacies are refusing to fill ivermectin prescriptions. The following pharmaciesThe pharmacieshave such prescriptions. Select one or make your own suggestion if you know they take such prescriptions
TeleHealth & Follow-Up Authorization: I give permission to this office to treat me by meansTeleHealth meansof telehealth services pursuant to Governor Newsom's Order of April 3, 2020, toof tocommunicate with me through the email address provided above, and to contact me bycommunicate byemail not more than once per week for a short follow-up inquiry on my prevention and/or treatment program only.

Required HIPPA Privacy Practices Notice: View our privacy practices here

HIPPA Notice Provided?
Required Medical Board of California Notice To Consumers: Richard B. Fox, M.D., J.D., 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.licensed Click "yes" to acknowledge receipt of this legally required notice.

The charge for this service is $75, payable by Zelle (Zelle details here) to phone number 408-402-2452. We will send you your evaluation and recommended treatment before payment but payment must be received before your prescriptions can be sent to your pharmacy.

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