Online Patient Appointment & Consent Form

Online Patient Appointment & Consent Form
Please note if you have any type of insurance (Medicaid, Medicare, ObamaCare or etc) or are finiacially capable to afford to see a doctor then please do not proceed to request an appointment.

This service is ONLY for those who do not have insurance and are not financially able to afford basic health services.

Our EHR system checks if you have insurance and if we discover that you do have insurance, then you will not be given an appointment and any existing appointments will be cancelled.
You are legally agreeing to the above statement and confirming by clicking "YES" *
Appointment Type *
Please note, if you are requesting an appointment with the Gynecologist for a Well Woman Visit, the earliest appointment available is in June 2021.
Reason for Appointment *
Patient’s Full Name *

First Name Last Name
Date of Birth: *

Month Day Year
DOB
Gender: *
Are you currently pregnant? *

Yes No Not Applicable
Email: *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Cell Number *

Area Code Phone Number
Alternate Number

Area Code Phone Number
Marital Status *
Preferred Pharmacy *
Name and Phone Number
Spouse/Significant other Information
Spouse Full Name

First Name Last Name
Contact Number

Area Code Phone Number
Do you have Insurance *
Primary Insurance Company: *
Emergency Contact Person
Emergency Full Name *

First Name Last Name
Friend or Family *
Phone Number *

Area Code Phone Number
Medical History:
Please indicate if you have experienced any of the following medical conditions: *

High Blood Pressure High Cholesterol Stroke Thyroid Disorder Diabetes Anemia Kidney Problems Cancer Skin Disorder NONE
Other (specify):
Allergies: Please indicate in writing if you have any allergies to medications, food, or vaccines, etc *
Medications: (List your prescription & over-the-counter medications including dosage instructions). *
Family History:
(Please indicate in writing if there is any history of High Blood Pressure, Diabetes, Heart Disease or other medical problems in your family). *
Smoking *

YES NO OCCASIONAL
Notice of Privacy Practices, Release of Billing Information, Consent for Treatment and Assignment of Benefits.
I have read and understand the terms in the above document and agree to the eCommunications disclosure agreement and telemedicine services. *

CLICK HERE
Patient Full Name: *
First Name Middle Initial Last Name
Date: *

Month Day Year
Date
Are you signing in for a minor? *
If patient is minor, please specify the relationship to the patient
Your Name:
First Name Middle Initial Last Name
Take a picture of a valid form of ID (driver license, passport, greencard, etc).
Should be Empty:

Online Patient Appointment & Consent Form

Emergency Contact Person

Medical History:

Family History: