FEMM Clinic Patient Information (Telehealth)

FEMM Health Form
Name*

First NameLast Name
Legal Sex*
Date of Birth*

MonthDayYear
Date
Preferred Name (if different than legal)
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Phone Number*
Please enter a valid phone number.
Email*

Confirmation Emailexample@example.com
Is it ok for FEMM to call, text, and email you?*
Race*
Ethnicity*
Marital Status*
Photo of Your Driver's License*
How did you hear about FEMM?*
Would you like to be billed through Insurance or Self-Pay?*
If booking an appointment with Julie Baltz, PA-C, Megan Blum PA-C, or James Tuljus PA-C, we can either bill your insurance out of network or you can self-pay.
Photo of the Front of Your Insurance Card
Photo of the Back of Your Insurance Card

FEMM Notice of Privacy Practices

Please review FEMM's Notice of Privacy Practices below.

FEMM Release of Billing Information & Assignment of Benefits, and Privacy Notice Acknowledgement

Please review the page below & sign to consent.
Please sign below if you agree to the terms above & grant FEMM the authority to download your medication history from pharmacy benefit managers (PBMs):*

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FEMM Health Form