Agoraphobia Treatment Online - Describe Your Illness

Step 1

Book Consultation
Step 2

Describe Your Illness
Step 3

Payment Process

Please complete your booking within the timeline.
Otherwise, you will be redirected back to start the booking and lose the time slot.

describe your Symptoms or Concerns

Please describe what you need help with today.

Include:

Your symptoms
When they started
How they’re affecting you

If you are requesting a medication refill, please include:

Name of the medication
Dosage
How often you take it
How long you’ve been using it

This will help your doctor prepare and ensure safe treatment.

Are you currently taking any medications (including prescription, over-the-counter, or supplements)?

Yes NO

Example: Cetirizine 10 mg, once daily, for 6 months

Are you requesting a prescription refill?

Yes NO

Example: Cetirizine 10 mg, once daily, for 6 months

Do you have any allergies to medicines or other substances?

Yes NO

Do you have any pictures or documents to share with your doctor?

Yes NO

What is your current blood pressure?

What is your height?

Metric (cm)

Imperia (ft/in)

What is your weight?

Metric (kg)

Imperial (lbs)

Do you have any of the following medical conditions?

Diabetes
Hypertension
Asthma or COPD
Heart disease
Mental health conditions
Other
None of the above

Which country country are you currently in?

This is needed for legal compliance and prescription validity.

Do you have private health or travel insurance and need a reimbursement form, a “Fit to Fly” certificate, or a “Not Fit to Fly” certificate?

Yes NO

BOOK consultation