Schedule a telehealth visit with Tara Mendietta

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Step 1: Provide your contact information and select your appointment date & time
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Please confirm that you are in Texas* This field is required.
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What is your legal first and last name?* This field is required.
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What is your date of birth?* This field is required.
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If you are the parent or legal guardian of the patient, or paying for a visit for someone else, please provide your name below.
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To order prescriptions, refills, labs, or referrals, we will need your Social Security Number. If you need any of these services, please provide this information.
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What is the best cell phone number to reach you at?* This field is required.
Please enter a valid phone number.
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What is the best email to reach you at?* This field is required.This is the email that we will send the telehealth link to.
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Please provide your address
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What is the reason for your appointment?* This field is required.Select all that apply!
I'm sick!
Preventive visit
New medications
Refill a prescription
I need labs ordered
I need a referral
Other
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What is the preferred pharmacy that you use?Please provide the address of the pharmacy in the event that you need a prescription or a refill.
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Ok
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Schedule the date and time for your telehealth appointment* This field is required.
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My Products* This field is required.
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Great Product Name
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Quantity:1
Size:Small
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Great Product Name
$20
Quantity:1
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ORDER SUMMARY
Total costUSD
Telehealth sick visit with TaraChoose this for sick visits, establishing care, and back to school visits.
$49.99Edit
Back
Initial Weight Loss Consultation with TaraIncludes lab orders & review, diet consultation, and medication order (if applicable)
$150.00Edit
Back
Weight loss follow up - established patient with TaraIncludes follow-up diet discussion, medication refills, and future lab orders
$100.00Edit
Back
Enter Coupon
Total cost $0.00
First Name
Last Name
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Take a picture of your ID. This should match the name on your credit card.
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Step 3: Complete Consent Forms

Last step! Please complete the following 4 notices. At the end of the notices, you will be asked to provide your signature.

In order for our nurse practitioner to treat you or make lab or prescription orders, we need to receive the next 4 consents from you.
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General Consent* This field is required.
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Telehealth Consent* This field is required.
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Financial Policy & Disclosure* This field is required.
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Patient Health Information Consent* This field is required.
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In the future, our practice will be taking insurance. Which insurance do you have, so that we can know once we get in network?
Medicare
Medicaid
BCBS or Anthem
United Healthcare
Humana
Cigna
Aetna
Other
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Please provide your signature* This field is required.Sign with your finger!
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Please provide today's date* This field is required.
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Thank you for scheduling with me!
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