Telemedicine Patient Information Form

Telemedicine Patient Information Form
Telehealth is the most comfortable way of having a live healthcare service in your safe home.
You must fill out the following fields and choose the day and date that suit you best so we can hold the spot for you. Once we check the integrity of your information, you will receive a unique link via email to start your online visit.
Please also provide your insurance details if you have any, so we can check your insurance policy. Depending on your insurance agreement, certain deductibles and co-payments may be needed. If you don't have any insurance, you will be charged of a falt flee of $100.
Name
First NameLast Name
Email
example@example.com
Phone Number
Area CodePhone Number
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date Of Birth
MonthDayYear
Date
Medical History*
Do you have any health insurance?
YesNo
Should be Empty: