Prescription Refills Online (Existing Patients)

Dr. Angela Straface is a board-certified MD and 25+ year Frontline Doctor available in every state. Through telemedicine, we can offer convenient and affordable healthcare services to patients.

This form is only for EXISTING patients.

We do kindly ask that all information is correct to include pharmacy numbers and fax numbers so that your prescription is not delayed. Thank you!

Has Dr. Straface written a prescription for you in the past year?

If no and Dr. Straface has not written a prescription in your name in the last year, we cannot fulfill this prescription refill request. Please call our office at (972) 656-1200.

First Name

Last Name

Phone

Physical home address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Date of birth:

What prescriptions are you taking currently? Please list the prescription names and dosage amounts:

What prescriptions would you like to request today with Dr. Straface? Please list prescription names:

For medical compliance requirements, please give your most recent blood pressure reading:

What is your current weight?

Which of the following do you request for your prescriptions? Please note that all controlled substances are a 30-day supply only.

2 Refills
90 Day Supply
30 Day Supply

Any allergies to medications?

Any medical issues?

Do you have a known heart condition?

Please choose one below:

If yes, please explain your heart conditions:

Do you have a family history of heart conditions?

Please choose one below:

If yes, please explain your family history of heart conditions:

Pharmacy name

Pharmacy phone:

ATTENTION PATIENTS, THIS IS VERY, VERY IMPORTANT.

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

The PHARMACY FAX NUMBER must be correct or it could delay your prescription by 3 days, also 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!

Please confirm pharmacy fax number below (must be correct):

Please answer the following questions below for your patient card with Feel Ideal 360 / Dr. Straface.

I am a current Patient of Dr. Straface:

If no, we cannot fulfill this prescription refill request. Please call our office at (972) 656-1200 and schedule a telemedicine visit with Dr. Straface.

Dr. Straface has issued the exact medication prescription for myself before:

If no, we cannot fulfill this prescription refill request. Please call our office at (972) 656-1200.

Medical Disclaimer

NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.

Patient agrees to virtual e-visit and/or prescription refill service terms, privacy policy, and charge for receiving a virtual visit and/or online prescription refill request from Dr. Straface at Feel Ideal 360.

Requests for e-visits and/or online prescription refills must be confirmed and scheduled by our office prior to the e-visit and/or online prescription refills. 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 the 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 prescription refill via online with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

Signature

I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. Straface to proceed with our telemedicine visit.

Date

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

In the event that my treatment plan includes shipped material, I understand Feel Ideal 360 is adding insurance to my order through USPS or FedEx to cover the cost of any loss or damage to my order while shipping. If my package is damaged, lost, or stolen, I will file a claim with USPS for financial reimbursement. Feel Ideal 360 is NOT responsible for delayed, damaged, lost, or stolen packages, and will NOT be reshipping delayed, damaged, lost, or stolen packages at this time.

Please check the box below to agree:

I agree

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Sub Total

$85.00

TOTAL

$85.00

Payment Method

Credit Card - Square

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Prescription Refills Online (Existing Patients)

We've received your Prescription Refill Form