DEMO PREVIEW — This is a working preview of the Evolve Health online questionnaire. It is NOT a real medical intake. Do not enter real health information — nothing you type or upload is sent, saved or stored.
EVOLVE HEALTH
(940) 257-2002
Stop and get urgent care: Call 911 or go to the emergency department for a severe headache with fever, neck stiffness, confusion, or sensitivity to light; trouble urinating (you cannot pass urine); sores spreading to or pain in an eye; severe pain; or signs of widespread blistering skin infection — these can signal a serious complication.

Herpes treatment works best when it starts early — ideally at the first tingle, itch, or burning before blisters appear. If you are having a first-ever outbreak, this form will route you to a video or in-person evaluation instead (see below), because a first outbreak needs a Clinician to confirm the diagnosis.

Completing this form does not guarantee a prescription. A Texas Clinician reviews every case and decides whether treatment is safe and appropriate.

Your privacy matters: no condition name appears on your card statement descriptors from us beyond "Evolve Health." Prescriptions sent to your own pharmacy follow that pharmacy's normal labeling.

Step 1 of 12 — Eligibility gates

Are you having any urgent symptom listed above right now? *
I confirm each of the following (all must apply): *

Step 2 of 12 — About you

How may we contact you about this care? *
May we leave a generic voicemail (no medical details)? *

Step 3 of 12 — Identity verification

Before a Clinician can prescribe, we verify identity — this protects you and keeps online care safe. Upload a clear photo of your government-issued ID (driver license, state ID, or passport) and a selfie. The name and date of birth on the ID must match this form. Your ID and selfie are stored only in your secure chart. If your ID cannot be fully verified, any prescription is pickup only.

Prescriptions are picked up at your own pharmacy. If your ID cannot be verified, a video visit may be needed first.
Photo of the FRONT of your government ID *
Demo only — files are never uploaded.

Use whichever is easier — Take a photo opens your camera right here, or upload a photo you already have.

Photo of the BACK of your ID — the barcode side *

The barcode on the back must match the front of your ID. This is how we confirm the ID is genuine.

Selfie *

Look at the camera like a passport photo — no sunglasses or hat.

Identity confirmation *

Step 4 of 12 — Your concern and goals

What would you like help with? Check all that apply. *
Where do outbreaks occur? Check all that apply. *

Step 5 of 12 — Diagnosis history and outbreak pattern

Online treatment is for people whose herpes diagnosis has already been confirmed by a clinician. A first-ever outbreak looks like several other conditions and needs an in-person or video evaluation with an exam (and often a swab test) before treatment — that protects you from a wrong diagnosis.
Has a clinician (doctor or other licensed clinician) ever diagnosed you with cold sores / oral herpes or genital herpes? *
How was the diagnosis made? Check all that apply. *
How many outbreaks do you typically have in a year? *
Are you having an outbreak right now? *
Outbreak (episodic) treatment works best when started at the very first tingle — ideally within the first day. Tell us honestly when symptoms started; if too much time has passed for this outbreak, the Clinician may recommend suppressive therapy or medication to keep on hand for the next one instead.
What seems to trigger your outbreaks? Check all that apply.
Which herpes medicines have you taken before? Check all that apply.

Step 6 of 12 — Safety screens (kidney, pregnancy, immune status)

Valacyclovir is cleared by the kidneys, so kidney health changes how it can be prescribed. Answer honestly — a "yes" does not end your care; it helps the Clinician choose a safe plan, which may be a video or in-person visit.
Check YES for any that apply to you:
Could you be pregnant, are you currently pregnant, or are you breastfeeding? *

Step 7 of 12 — Red-flag exit list

Some symptoms mean online care is not the right setting. If any of the following apply, stop and use the route shown — do not wait for an online reply.
Check any that apply to you right now:

Step 8 of 12 — Health history

Check every condition you have now or have had before: *

Step 9 of 12 — Medicines and allergies

Have you ever had a reaction to valacyclovir, acyclovir, or famciclovir (for example rash, swelling, confusion, or reduced urination)? *

Step 10 of 12 — Lifestyle and wellbeing

Cannabis or other recreational substances? *
During the past 2 weeks, have you often felt down or depressed, or had little interest or pleasure in things? *
Are you currently thinking about harming yourself or someone else? *
Any concern about another sexually transmitted infection, or need for testing? *
Herpes care does not test for other infections. If you would like STI testing, we can arrange it at our Denton clinic or by referral — just let the Clinician know.

Step 11 of 12 — How you will receive medication

If the Clinician prescribes, your prescription goes to your own pharmacy for pickup — recommended for a first fill, and the only option if your ID could not be verified. Your insurance can pay for the medication there.
Pharmacy pickup: *

Mail delivery is available for most medications — not all. Some medications need refrigeration or special handling, and some addresses can't be reached by mail. If mail isn't possible for your medication or your address, we'll tell you before you pay, and your prescription will go to your pharmacy for pickup instead — no extra visit charge.

Step 12 of 12 — What happens next + consent

After review, a Clinician may: ask follow-up questions or verify your identity and location; request records or lab tests (for example kidney labs); schedule a video or in-person evaluation — always the route for a first-ever or unconfirmed outbreak; recommend testing for other infections; or recommend primary care, specialist, or emergency evaluation. No medicine is promised.

Payment: your exact price is shown before checkout. Your card is authorized when you submit and The fee covers your Clinician review and is charged once the review is complete, whether or not treatment is approved. Medication, if prescribed, is separate.
Type your full legal name to confirm each statement: *