PREVENTATIVE COVID-19 TELEMEDICINE INTAKE FORM

Dr. Angela Straface is a board-certified MD and 25+ year Frontline Doctor available in two states. Through telemedicine we can offer convenient and affordable healthcare services to patients. Telemedicine is an excellent option for nonemergency situations, including prophylactic (preventive) and early (home) treatment of COVID-19.

Dr. Straface is knowledgeable in hydroxychloroquine and ivermectin. She is aware of the science and data regarding its safety and efficacy.

Please fill out our COVID-19 questionnaire below. Please check if all information is correct, including pharmacy numbers and fax numbers, so that your prescription is not delayed. Thank you!

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

Ivermectin has a 30 year history of safe use in humans and the side effect profile appears mild for the most part. However, the past use of ivermectin does not predict the safety and side effects seen when used for COVID-19 because we are using much higher doses when treating and preventing COVID-19. For scabies and parasite infections the usual dose is one time 0.2mg/kg. For COVID-19 prevention the dose is 0.2mg/kg twice a week indefinitely. For acute treatment, the recommended dose is 0.4mg/kg daily until symptoms resolve and it may be continued for 7-14 days total. These doses are MUCH higher than any used in the past. Based on my experience they are still safe and in thousands of patients I have seen no lasting or serious reactions to high-dose ivermectin use, but my data is imperfect and there may have been serious or severe side effects.

Also when used on a new disease, side effects could be different than those recorded in the past. For example, the most severe side effects of ivermectin in the past were only seen in the setting of treatment for a certain parasitic disease. The other relatively common side effect that has been seen in the past is elevated liver function tests which could indicate liver damage, reported in 2% of patients. While on ivermectin you should get liver function tests done on a monthly basis. There are also a number of other more severe side effects seen less than 1% of the time. All that being said, Tylenol and Advil use has been shown to increase the risk of heart failure and death and those are available over the counter. All medications do carry some risk that you should be aware of and in our judgment the risk is acceptable, given the disease.

Alcohol can increase the blood levels of ivermectin, so should be avoided when taking ivermectin. Using alcohol with Ivermectin may increase the risk of side effects. These are the common side effects reported with ivermectin in general:

Cardiovascular: Tachycardia (4%), peripheral edema (3%), facial edema (1%), orthostatic hypotension (1%)

Central nervous system: Dizziness (3%)

Gastrointestinal: Diarrhea (2%), nausea (2%)

Not to be used in pregnancy, or by those who might become pregnant- sexually active women should use contraception.

RELEASE FROM MEDICAL LIABILITY AND MALPRACTICE CLAIMS: 

I acknowledge that off-label prevention and treatment for COVID-19 and related illnesses, like presumed post-viral syndrome due to COVID-19 AKA long COVID or long haul syndrome, has become a highly charged and political issue and poses numerous personal and professional risks to practitioners who prescribe these alternative, unapproved treatments, that, though presumed and believed to be safe and effective based on the best available evidence, may in fact be harmful and could cause severe disability and even death, which can in fact occur with any and all medical treatments in some percentage of patients, but physicians involved in these negative outcomes are shielded from liability when their peers agree their treatments were warranted. This is not the case with prevention and treatment of COVID-19 and related illnesses like long COVID. Where prescribing practitioners are acting outside the bounds of medical establishment consensus, therefore in order to obtain treatment that is not physician peer, FDA, NIH or CDC approved, but may nevertheless be beneficial, I agree to release Dr. Angela Straface and all her associates from all medical liability and malpractice claims related to any and all care, including but not limited to preventive, acute and chronic treatments for COVID-19 and presumed and/or diagnosed post-viral syndrome due to COVID-19, AKA long COVID or long haul syndrome.

 

YOU MUST AGREE TO THE TERMS MENTIONED ABOVE IN ORDER TO CONTINUE.


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ATTENTION PATIENTS, THIS IS VERY, VERY IMPORTANT.

*****TO KEEP YOUR PRESCRIPTION FROM BEING DELAYED****** 

We recommend you pick a COMPOUND PHARMACY. We are struggling with larger pharmacies supplying the scripted medication and/or scripts on time.  Please google "compound pharmacy in my area" and provide that pharmacy of choice below if possible. 

The PHARMACY FAX NUMBER must be correct or it could delay your prescription by 3 days, also an important note, we have found that pharmacists do not check their incoming digital faxes in a timely manner, we ask that you remind your pharmacists to check their computer for digital faxes. Thank you!

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. 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:

  • You may inquire with your own insurance company about reimbursement. We do not take insurance at this time.
  • 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
$125.00
TOTAL
$125.00

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We've received your COVID-19 Intake Form

Covid-19 Telemedicine Hours:

Hello, we've received your Covid-19 Intake Form. Our Feel Ideal 360 Team member will respond to you by the end of the business day.  Calls will be made until 11 pm central time to accommodate for high volume. 

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

Online Covid-19 SATURDAY/SUNDAY INTAKES WILL BE RETURNED within 48 hours.  Our offices are closed on weekends. Please do not all our office on weekends as our team will call you. 

Regarding your Upcoming – Telemedicine Call

Most big box pharmacies will not fill ivermectin nor hydroxychloroquine, especially Walgreens and CVS, which will significantly delay you getting your prescriptions. If you provided one of these pharmacies, we encourage you to find a:

  • compounding pharmacy or a local/non-chain pharmacy

  • call them to confirm they have it in stock and will fill it

  • have the new fax number ready when Dr. Straface calls you

Please see the supplement list for both below

  • *Covid-19 illness protocol and 

  • **Covid-19 prevention protocol

Follow the supplements to the letter, paying attention to the dosages. Taking aspirin daily, even if it’s just baby aspirin, is imperative for a minimum of three months post-illness to prevent post Covid stroke complications as well as clotting. 

*Covid ILLNESS Protocol (sick)

  • VITAMIN D 6000  I U a day – may divide into half twice a day
  • VITAMIN C 2000 mg  a day – may divide into half dose twice a day
  • ZINC 100 mg daily
  • QUERCETIN 500mg daily
  • MELATONIN 10 mg every night
  • Take TYLENOL 1000 mg every 4- 6 hours as needed for FEVER, body aches or headache.
  • Take MOTRIN 400 mg every 4 hours as needed for FEVER, body aches or headache. (May take with the Tylenol at the same time)
  • Aspirin 325 mg OR 4 baby aspirins DAILY FOR AT LEAST THREE MONTHS to prevent post Covid clotting complications (unless contraindicated)

**Covid PREVENTION Protocol (not sick)

  •        VITAMIN D 6000 IU a day – may divide into half twice a day
  •        VITAMIN C 2000 mg a day – may divide into half dose twice a day
  •        ZINC 50 mg daily
  •        QUERCETIN 500 mg daily
  •        Prescription Ivermectin

We appreciate your patience during this busy time. Please note, calling our office may only further delay the process given the extraordinary number of calls are receiving. Please email us should you need additional assistance.

Dr. Straface and the 

Feel Ideal 360 team

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