[TM] Telemedicine OMMP Appointment Questionnaire
To help you towards a successful OMMP Appointment to obtain your required Physician Approval Forms, please follow the instructions in this questionnaire.
READ INSTRUCTIONS CAREFULLY
DO NOT USE THE Back or Forward buttons on your internet browser while doing this application!! You will lose all your inputs.
Please only use the "NEXT" or "BACK" buttons at the bottom of these questionnaire pages.
*Please complete this application and submit all required documents at least 48hrs prior to your appointment to avoid appointment cancellation (unless otherwise arranged with our staff)
* Make sure your information is correct! Double-check Spelling of Names, DOB, Email and Phone numbers
* If you booked a "Discounted OMMP Appointment ($130)" please have your proof of benefits such as OHP, SNAP, SSI (not SSDI or Social Security) or Military Service ready as a picture or scan on your device for upload into this form
*If taking a picture of your documents with your phone/tablet-- please use a clean WHITE BACKGROUND and make sure the document is IN FOCUS.
*If you are unable to upload files via this application for any reason -- you can also email the required documents to our office at: firstname.lastname@example.org
Let's Get Started!