CARY ADULT MEDICINE

Name Date of Birth

Please check with your insurance to see if they recognize E-Visits as covered services. Medicare/Tricare/Aetna/UHC and some BCBS plans do not recognize E-Visits. The charge for a non-covered E-Visit is $40

When was your last yeast infection? How many times have you been treated for a yeast infection in past 1 year? Have you recently taken any antibiotic? Have you tried to treat this infection with any over the counter yeast infection treatments Have you had any pelvic or abdominal pain ? Do you have? Have you taken Diflucan for a yeast infection before? When was your last period Are you pregnant? Please Include any other information