Telehealth
4pm-7pm
Check in Opens at 4pm Monday to Thursday
Today's Appointment Date
*
/
Month
/
Day
Year
Date of Visit
Current Time
*
Hour Minutes
AM
PM
AM/PM Option
Payment for Session (Will be Rescheduled if Payment Not Made) -
*
Private Pay
Current Insurance Policy
New Insurance Policy
Upload Insurance Card(s) Back and Front of Card
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Payment Authorization:
*
By checking off you authorize the Practice to Charge Credit on File if a fee is due: The payment policy of the practice allows them to use the payment method saved on file to cover any outstanding balances, including fees for late cancellations or no-shows, without requiring additional authorization. However, if you do not have a copay or wish to use a different card that is not saved on file, or if you do not have any payment method saved on file, the practice will contact you to arrange for payment if necessary.
Audio Recording Consent
*
I consent to audio recording of our clinical sessions using Nextvisit Ai software for the purpose of providing optimal care and documentation for your session. I understand that these recordings will not be stored for more than 30 days.
Pharmacy Information Confirmation:
*
Pharmacy on File (No Changes)
Different Pharmacy (Name of Pharmacy and Address, Including Zip Code)
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date of Birth
Mobile Phone Number
*
Please enter a valid phone number.
Schedule Your Next Follow Up Appointment Now
Next Telehealth Appointment Requested
Start Online Session
Should be Empty: