Test Phone 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 Reason for Calling today (Visit) * Cough Cold Fever Sore Throat Vomiting Headache Allergies Asthma Rash Anxiety Diarrhea UTI Earache (Right / Left / Both) Body aches/Chills Nausea Painful Urination Other if Other please describe 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
