Telemedicine for Urgent/ Primary Care

APPOINTMENT REGISTRATION

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

First Name Last Name
Date of Birth *

Month Day Year
Date
Sex *

Male Female Prefer not to say
Marital Status *
Home Address *

Street Address

Street Address Line 2

City State / Province

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

Month Day Year
Please indicate any/ all medications you are currently taking *
Please list all allergies, or type N/A if you have none *
Patient Billing Information
Telemedicine appointments are CASH PAY ONLY. Do you understand that you will not be able to use insurance for your appointment? *

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