Telemedicine - Family Internal Medicine

Please complete the form below. Make a payment for

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 *

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

Checkbox for permission *

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.

Signature *

Clear Signature

Sign by hand

Date *

Select date

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

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

Select from Dropdown Items

Select one

Enter Credit Card Information *

Thank you.