www.synergyinsurance.net 1-866-710-0908

Group Name: Synergy

Group Number: 23631

Work status note to be sent to Employer via:

☐ Email: ________________________________________________ ☐ Fax: ___________________

Patient Name:

Date of Birth: ☐Male ☐ Female

Height: _________________ Weight: _______________

What State are you currently in? ___________________

Home Address: ________________________________________________________________________

________________________________

Call Back Phone #: ________________________ Preferred Pharmacy Phone #: ______________________

Email address: ______________________________________________________________________________

☐ An Interpreter is needed. Please note language: _________________________________________________

Reason for Consultation: ______________________________________________________________________

__________________________________________________________________________________________

Employer Name: ____________________________________________________________________________

Select one from the following options:

☐ I authorize for my medical records and any applicable restrictions to be emailed to the address noted above

☐ I authorize for my medical records and any applicable restrictions to be faxed to me at: ___ ________

The physician will be calling you to conduct a medical consultation within one hour, but typically within 15 minutes.

**Please note that after 10pm EST/9pm CST a doctor will return your call the next day**

PLEASE COMPLETE ALL PARTS OF THIS FORM AND SEND TO OUR SECURE FAX LINE 866-452-5611 or EMAIL (via secure e-mail) TO memberservices@1800md.com

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Workers’ Compensation Initial Treatment

**If form is faxed, please call 1-800-530-8666 to confirm receipt**

www.synergyinsurance.net 1-866-710-0908

Personal Medical History

Please check the following conditions that apply to you: _____ Anemia _____ Lung Disease _____ Anxiety/Depression _____ Pneumonia _____ Arthritis _____ Reflux (GERD) _____ Asthma _____ Rheumatic Fever _____ Bleeding Disorder _____ Seizure Disorder _____ Blood Clots _____ Serious Injury _____ Cancer (type: ___________________) _____ Skin Disease _____ Diabetes _____ Stroke _____ Digestive/Gastrointestinal _____ Thyroid Disease _____ Gall Bladder problems _____ Tuberculosis _____ Heart Disease _____ Urinary Problems _____ Heart Murmur _____ Vision Problems _____ Headaches _____ Other: _____________________ _____ High Blood Pressure _____ Other: _____________________ _____ High Cholesterol _____ Other: _____________________ _____ Kidney Disease _____ Liver Disease

Please list prior surgeries, hospitalizations and procedures:

Please list prior alternative treatments such as acupuncture, chiropractic, etc.

www.synergyinsurance.net 1-866-710-0908

Medications:

Please list any vitamins, supplements, herbal, homeopathic remedies, and their doses:

Allergies:

List all medications, foods, medical tests, etc. and the nature of your reaction:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Women Only:

1st day of last menstrual period: ____________ Could you be pregnant? ____ _

Are you using birth control? _______ If yes, what type? ______ _____

Name Dosage Frequency

www.synergyinsurance.net 1-866-710-0908

Patient Name: ____________________________________

1. I understand that I am engaging in a telemedicine consultation.2. Phone conferencing technology will be used to affect such a consultation and will not be the same as a direct patient/health

care provider visit due to the fact that I will not be in the same room as my health care provider.3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical

difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that thephone conferencing connections are not adequate for the situation.

4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Ifurther understand that I can terminate the consultation at any time.

5. I have had the alternatives to a telemedicine consultation explained to me, and in choosing to participate in a telemedicineconsultation, I understand that some parts of the exam involving physical tests may be conducted by individuals at mylocation at the direction of the consulting health care provider.

6. In an emergent consultation, I understand that the responsibility of the telemedicine consulting specialist is to advise me ofthis and that the specialist’s responsibility will conclude upon the termination of the phone conference connection.

7. 1800MD does not guarantee prescriptions. It is up to the physician to recommend the best course of treatment.

By signing this form, I certify: That I have read or had this form read and/or had this form explained to me; That I fully understand its contents including the risks and benefits of the procedure(s); and That I have been given ample opportunity to ask questions and that any questions have been answered to

my satisfaction.

________________________________________ _________________ _______________

Patient’s/Parent/Guardian Signature Date Time

PLEASE COMPLETE ALL PARTS* OF THIS FORM AND FAX TO OUR SECURE FAX LINE866-452-5611 or EMAIL (via secure e-mail) TO memberservices@1800md.com

**If form is faxed, please call 1-800-530-8666 to confirm receipt**

*Incomplete forms will delay consultation call-back time