We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.
What was your sex assigned at birth?
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Are you currently pregnant, breastfeeding or planning to become pregnant?
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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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Medical history
Medical history
Do you have a known history of cold sores?
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Medical history
Medical history
How often do you experience outbreaks within a 12 month period?
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Medical history
Medical history
Are you seeking short-term relief of your current outbreak symptoms or long-term suppression for future outbreaks?
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Past treatments
Past treatments
Which treatment have you tried in the past:
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Medical Conditions
Medical Conditions
Where are the lesions located?
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Medical Conditions
Medical Conditions
What does your lesion look like?
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Please attest to the following confirming that all information you have provided to us is true and complete.
Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided
Consent: I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided
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Consent (Medication Specific):
Consent (Medication Specific):
Please read the following IMPORTANT information to learn about the use of this product including side effects.
Famciclovir, acyclovir, valacyclovir, and topical antivirals are medications used to manage viral infections (such as herpes simplex) and their associated symptoms.
Purpose of Treatment
Potential Benefits
Contraindications
Potential Risks and Side Effects
Monitoring and Follow-up
Alternative Treatments
Patient Responsibilities
Consent
By agreeing below, you acknowledge that you have read and understood the information provided in this consent form. You agree to proceed with treatment under the conditions outlined above
Famciclovir, acyclovir, valacyclovir, and topical antivirals are medications used to manage viral infections (such as herpes simplex) and their associated symptoms.
Purpose of Treatment
- Famciclovir, Acyclovir, Valacyclovir: Oral antiviral medications that help reduce the severity and duration of outbreaks or infections caused by herpes simplex and other related viruses. They work by inhibiting viral replication, thus helping to alleviate symptoms and potentially shorten the healing time.
- Topical Antivirals: Applied directly to affected areas (such as acyclovir cream). They help reduce local symptoms, lesion size, and may expedite healing.
- Symptomatic Management: Includes measures such as pain relievers, antihistamines, topical steroids or other supportive therapies to relieve pain, itching, and discomfort.
Potential Benefits
- Relief of symptoms (e.g., pain, burning, itching).
- Reduced severity and duration of outbreaks.
- Potential decrease in frequency of future outbreaks.
- Improved quality of life by controlling or alleviating symptoms.
Contraindications
- Famciclovir, Acyclovir, Valacyclovir:
- Known allergy or hypersensitivity to these medications or their components.
- Certain kidney conditions may require dose adjustments.
- Use caution in patients with significant immunocompromise or other serious health conditions—your provider will evaluate your case.
- Topical Antivirals:
- Known allergy to the active or inactive ingredients in the topical formulation.
- Severe skin reactions or open wounds at the site of application (your provider will guide you on proper use).
Potential Risks and Side Effects
- Famciclovir, Acyclovir, Valacyclovir:
- Gastrointestinal upset (nausea, diarrhea)
- Headache, dizziness, or fatigue
- Allergic reactions (e.g., rash, itching, swelling)
- Rare but serious side effects include confusion, tremors, kidney dysfunction, or blood abnormalities
- Adjustments might be needed if you have kidney disease
- Topical Antivirals:
- Mild skin irritation, redness, or itching at the application site
- Allergic reactions (rash, swelling) in rare cases
Monitoring and Follow-up
- Regular monitoring or follow-up appointments may be recommended to assess effectiveness and detect any adverse effects.
- Inform your healthcare provider of any new or worsening symptoms, or if you experience any unexpected side effects.
Alternative Treatments
- Watchful Waiting: Allowing the outbreak to resolve on its own without antiviral intervention (may result in longer or more severe symptoms).
- Other Prescription or Over-the-Counter Medications (as deemed appropriate by your provider).
- Lifestyle Measures: Stress management, adequate rest, nutrition, and avoiding known triggers.
Patient Responsibilities
- Take medications exactly as prescribed (e.g., dose, frequency, duration).
- Report any side effects or adverse reactions to your healthcare provider promptly.
- Keep all follow-up appointments to monitor your response to treatment.
- Inform your provider of any changes in your health status, medications, or allergies.
Consent
By agreeing below, you acknowledge that you have read and understood the information provided in this consent form. You agree to proceed with treatment under the conditions outlined above
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Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.
What you were seeking help for:
• Cold Sores
Why this happens
Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.
