• Telemedicine Visit

    Telemedicine offers a convenient way to conduct appointments remotely, eliminating the need for an office visit. Please complete the form below.

  • If you are going to use insurance, please call 818-906-6900, prompt 1 for verification before moving forward with the form.

  • Are you planning on using insurance for this visit?*

  • If you are going to use insurance, please call 818-906-6900 for the verification code.

     

  • Are you located in California?*
  • Pregnant or planning*

  • We're sorry, we cannot prescribe medication if you are pregnant or planning pregnancy.

  • Breastfeeding*

  • We're sorry. We cannot prescribe medications if you are breastfeeding.

  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year
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  • Chief complaint:*
  • Do you have any of the following symptoms?*
  • Have you tried any medications?
  • Medical Conditions*
  • Do you agree to correspond about secure medical information via email?*

  • PLEASE NOTE: If you have Medicare, Medicare will be billed, and you will not need to make a payment. If you have non-Medicare insurance, please select your co-pay amount.

  • Type of Insurance*
  • Would you like to add a video chat to your visit for an additional $40.00?*
  • Would you like to schedule a video chat with the provider?*
  • If you choose to schedule a video chat, you understand that the platform is Doxy.me?*
  • Copayment Amount*

  • Payment Required:

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    USD

    Credit Card
  • Should be Empty: