TELEMEDICINE - Family Internal Medicine

Please complete the form below. Make a payment for

Medical Consultation for up to 15 mins (16 years or older) – $60
Detailed Medical Consultation up to 30 mins – $120
Weight Loss consultation – $85
Suboxone opioid Treatment $100

Note: Currently, we are accepting patients in PA state only for Telemedicine. We will be adding the other states soon.

Once our staff receives your completed form and the payment, you will receive a text for the time of your appointment.

Purpose of Telemedicine *

give details of medical consultation required

Name *

First

Last

Multiple Choice *

Male
Female

select one

Patient D.O.B. *

D.O.B. format mm/dd/year

Driver License # and State of License *

if none, write none

Cell Phone

for patient

Email *

Confirm Email

if none, write none

Home Address *

-Patent's Home Address

City, State, Zip Code *

for patient

Name of Pharmacy, Address, City and State, Zip

Give location address of Patent's Pharmacy

By signing below, I authorize the use of my health information for medical consultation. I authorize direct payment to my physician. I permit a copy of this authorization to be used in place of the original.

write your name

If patient is less than 18 years of age, Name of Parent *

if patient is 18 years or older, write N/A

Enter Credit Card Information *

Select from Dropdown Items

Select one

Thank you.