Important Note: Our providers are only licensed to treat patients within the United States. Please only complete this form if you currently reside in the U.S., as we are unable to ship Caya internationally.

Next Steps:

● Complete the form with your information.

● We will contact you by phone to schedule a telehealth appointment.

● You will meet with a provider, and if Caya is appropriate, a prescription will be
written and submitted to our mail order pharmacy.

● Caya will be shipped to your preferred address using our mail order
pharmacy.

Please Note: Your prescription will be sent to the Tampa Specialty Pharmacy which
may have additional charges.

Our office uses athenahealth, a secure and trusted electronic health record system that includes a convenient patient portal designed to help you stay connected to your care. Through the portal, you can easily access your medical records and test results, send secure messages to our office, request or manage appointments, complete forms ahead of your visit, participate in telehealth appointments when available, and view or pay bills. The patient portal gives you safe, 24/7 access to your health information and helps streamline communication with our care team from your computer or mobile device.

How to download the athenaPatient app:

• Apple App Store (iPhone/iPad):
https://apps.apple.com/us/app/athenapatient/id1644169294

• Google Play Store (Android):
https://play.google.com/store/apps/details?id=com.athenahealth.athenapatient

Once you are a registered patient in our system, you will receive an invitation to create your own username and password, which will be securely linked to the patient portal.