Self-Schedule a Telemedicine Visit.
Are you seeking an after hours or weekend appointment?
No.
Yes. (Continue to complete this form. We strive to accommodate all needs and will contact you via email to inform you of any availability outside standard business hours.)
Name
*
First Name
Last Name
Email of Primary Account Holder
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Please enter the date of birth of the individual requesting the appointment.
Chief Complaint / Symptoms?
*
Please describe the symptoms are you experiencing at this time?
Allergies?
*
Please list any allergies you may have to medication, food, or environmental factors.
Current Medications or Supplements?
*
Please list any medications or supplements you are currently taking.
Company Name/Employer
Do you receive Modern Medika through your employer? If not, leave blank. We deeply value your privacy and absolutely NO Personal Information will be shared with your employer.
Terms and Conditions
*
Signature
*
Submit
Should be Empty: