If this is a medical emergency please call 911. Do not rely on communication through this website for urgent medical needs. Please note all patients are subject to co-pays and deductible at the time of service.

Patient First Name

Patient Last Name

Date of Birth

Phone Number

Medical Insurance

Email Address

Type

No Insurance Existing Patient New Patient

Patient Home Address

Address Line 1

Address Line 2

Zip Code

City

State

Pharmacy Name

Pharmacy Address

Which device are you using for this visit: (Must have audio and video capabilities)

iPhone Android Laptop/Computer

Fill any that you can do at home:

Height:

Pulse/min:

Temp:

Weight:

Blood Pressure:

Respiratory Rate/min:

FEMALE ONLY

Last Menstrual Period

Are you Currently Breastfeeding?

Yes No

Are You Pregnant?

Yes No

Are you allergic to any medication?

Yes No

If Yes please list

Current medications:

Comments

How would you like to initiate your Telemedicine visit?

Email Text

Please be advised that by using this link you have provided verbal consent to conduct your visit via video chat. If you do not consent please call office to schedule regular appointment click here to review the informed consent.

Telemedicine Appointment

Complete the form below to schedule your appointment

Patient Home Address

Fill any that you can do at home:

FEMALE ONLY