Telemedicine for Urgent/ Primary Care

APPOINTMENT REGISTRATION

TELEMEDICINE - URGENT/PRIMARY CARE
Patient Contact Information
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
MaleFemalePrefer not to say
Marital Status*
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
E-mail
example@example.com
Patient Questionnaire
What is your primary concern for this visit?*
Appx. When did your symptoms start to occur?*

MonthDayYear
Please indicate any/ all medications you are currently taking*
Please list all allergies, or type N/A if you have none*
Patient Billing Information
Yes

Are you a new or returning patient?

(Telemedicine Visit) Urgent & Primary Care - New Patient

A telemedicine appointment specifically for Urgent or Primary Care needs. If you are not an established patient with Glofusion, you will need to choose this service.

$55.00

(Telemedicine Visit) Urgent & Primary Care - Returning Patient

A telemedicine appointment specifically for Urgent or Primary Care needs. If you are already an established patient with Glofusion, you will need to choose this service.

$45.00

Total

$0.00

Credit Card

Patient/Guardian Signature*

Clear
Appointment
Payment
Confirmation
Dear Patient,

Thank you for completing your patient paperwork prior to your telemedicine appointment.

Please call or text 404-301-7209 immediately to schedule your appointment. We are happy to accommodate in any way and schedule the most convenient time for you!
Should be Empty:

Patient Contact Information

Patient Questionnaire

Patient Billing Information

Credit Card

Appointment

Payment

Confirmation