Parasite Cleanse Telemedicine Intake Form

You are enrolling in the Feel Ideal 360 112 Day Parasite Cleanse, a physician-supervised protocol that includes structured supplementation, prescription medications when clinically appropriate, and targeted detox support. This intake form allows Dr. Straface to review your medical history, current symptoms, and medications so your plan can be finalized safely and appropriately. All prescriptions and advanced therapies require medical clearance and are provided only when clinically indicated. Please complete this form thoroughly and accurately to ensure proper guidance throughout your program.

Please fill out our questionnaire below. We do kindly ask that all information is correct, including pharmacy numbers and fax numbers, so that your prescription is not delayed. Thank you!

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Local to Feel Ideal 360? Enhance Your Cleanse with In-Office ALA IV Support

Adding three ALA IV infusions during your parasite cleanse can significantly improve how your body tolerates the elimination phases. As parasites are disrupted, they release metabolic byproducts that increase oxidative stress and burden the liver. Alpha-Lipoic Acid is a powerful antioxidant that supports mitochondrial energy production, enhances liver detoxification, and helps your body process die-off more efficiently. Patients who include ALA IV therapy often report improved clarity, steadier energy, and fewer intense detox reactions during transition phases. If you want a more comfortable, resilient, whole-body approach to this protocol, incorporating ALA support can make a meaningful difference in your overall experience.

Patient Medical Information

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Antiparasitic Medication Informed Consent

(Ivermectin and Mebendazole)

Please read these terms carefully and agree to the terms below.

As part of the Feel Ideal 360 110 Day Parasite Cleanse, you may be prescribed antiparasitic medications including ivermectin and/or mebendazole. These medications are used in structured cycles during the elimination phase of the protocol to disrupt and reduce parasitic burden under physician supervision.

Both ivermectin and mebendazole have long histories of medical use when prescribed appropriately. However, all prescription medications carry potential risks, and individual responses vary.

Purpose of Treatment

Ivermectin works by interfering with parasite nerve and muscle function, leading to immobilization and elimination.

Mebendazole works by disrupting parasite glucose metabolism, leading to parasite death.

These medications are used in timed cycles to align with parasite life patterns. Dosing and duration may differ from single-dose regimens historically used for isolated infections because this protocol is structured and cyclical.

Potential Side Effects

Most side effects are mild and temporary but may include:

Gastrointestinal: nausea, diarrhea, abdominal discomfort
Neurological: dizziness, headache, fatigue
Cardiovascular: tachycardia, mild blood pressure changes, peripheral swelling

Less common but more serious risks may include:

Elevated liver enzymes
Allergic reactions
Significant liver dysfunction
Severe gastrointestinal distress

Because these medications are metabolized through the liver, periodic liver function monitoring may be recommended during the protocol.

Alcohol and Medication Interactions

Alcohol may increase liver burden and may raise blood levels of these medications. Alcohol should be avoided during active antimicrobial phases of the cleanse.

You must disclose all medications, supplements, and medical conditions prior to starting treatment.

Pregnancy and Contraindications

These medications are contraindicated in:

  • Pregnancy
  • Individuals attempting to become pregnant
  • Advanced liver disease
  • Active gallbladder obstruction or severe biliary disease

Sexually active women capable of becoming pregnant should use appropriate contraception during treatment.

Acknowledgment of Risk

I understand that:

  • All medications carry inherent risks.
  • Side effects may occur, including rare but serious reactions.
  • Outcomes cannot be guaranteed.
  • Monitoring may be recommended during treatment.
  • I am responsible for reporting any concerning symptoms immediately, including abdominal pain, jaundice, rash, severe dizziness, or unusual fatigue.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS

I acknowledge that ivermectin and mebendazole are being prescribed as part of a structured, physician-supervised parasite protocol based on clinical judgment and individualized assessment.

I understand that no medical treatment is without risk, and adverse outcomes, including serious complications, may occur in a small percentage of patients.

I agree to release Dr. Angela Straface and her associates from medical liability and malpractice claims related to the use of these medications within this parasite cleanse protocol, except in cases of gross negligence or willful misconduct.

Medical Disclaimer 
NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.
Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Straface at Feel Ideal 360. 
Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. Prior to the visit please fill out our medical questionnaire. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing and/or treatment at a medical facility in-person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. Also, in the event that you cancel your telemedicine appointment, please be aware that a 3% processing fee will apply should a refund be requested. In addition, you agree to abide by our office's routine policies including any policy related to litigation. I acknowledge I am paying for a telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

Important:

  • The consultation fee does not include the cost of the medication prescribed. 
  • Also, if you are experiencing any technical difficulties with our automated processing form above please contact our office directly and one of our Feel Ideal 360 Team members will assist. Thank you! Phone: 972-656-1200
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Sub Total
$595.00
TOTAL
$595.00

We've received your Parasite Cleanse Telemedicine Intake Form

Telemedicine Hours:

Hello, we've received your Parasite Cleanse Telemedicine Intake Form. Our Feel Ideal 360 Team member will respond to you by end of next business day.

Very Important:  FOR THE NEXT 24-48 HOURS please answer ALL UNKNOWN AND/OR SPAM BLOCKED CALLS. Sometimes unknown numbers show up as spam and we don’t want to miss you. 

Dr. Straface will call you at her next available opportunity, so please be sure your phone settings for unknown/spam blockers are turned off. 

Dr. Straface and the 

Feel Ideal 360 team

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