Telehealth Appointment Request Form

Telehealth Appointment Request

Please complete and submit this form to request a telehealth appointment at Advanced Specialty Care or call (203) 830-4700.

For medical issues needing immediate response, please call 911; do not email through this form.
Appointment Type*
Please select the appointment specialty
Name of Patient*

First Name of PatientLast Name of Patient
Patient Date of Birth*

MonthDayYear
Are you a current patient?*

YesNo
Reason for Appointment:*
Contact Information
Is the appointment for you or someone else?

The appointment is for myselfThe appointment is for someone else
If you are not the patient, please enter your name so we may contact you

First NameLast Name
Phone Number*

Area CodePhone Number
E-mail Address
Should we contact you by phone or email?

PhoneEmailEither
Best time to reach you?
Practice Hours: M-F from 8:30am-5:00pm. Requests submitted outside of practice hours will be responded to on the next business day.
How did you hear about our practice?
Please check the box before submitting*
Should be Empty: