Schedule a Visit with Priscilla Agali

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Step 1: Provide your contact information and select your appointment date & time
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Please confirm that you are in Texas, Kansas, Missouri, Iowa, Minnesota, or Oklahoma * This field is required.
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We're so sorry, but this provider only sees patients in Texas, Kansas, Missouri, Iowa, Minnesota, and Oklahoma at this time.

Please cick here to return to our website to find a nurse practitioner in your state.
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What is your legal first and last name?* This field is required.
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What is your date of birth?* This field is required.
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To order prescriptions, refills, labs, or referrals, we will need your Social Security Number. If you need any of these services, please provide this information.
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What is the best cell phone number to reach you at?* This field is required.
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What is the best email to reach you at?* This field is required.This is the email that we will send the telehealth link to.
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Please provide your address
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What is the preferred pharmacy that you use?Please provide the address of the pharmacy in the event that you need a prescription or a refill.
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What is the reason for your appointment?* This field is required.Select all that apply!
I'm sick!
Preventive visit
New medications
Refill a prescription
I need labs ordered
I need a referral
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Schedule the date and time for your telehealth appointment* This field is required.
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Step 2: Make Payment* This field is required.You're half way done!
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ORDER SUMMARY
Total costUSD
Initial Weight Loss Visit with PriscillaSelect this for your first weight loss visit
$60.00Edit
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Subsequent Weight Loss Visit with PriscillaSelect this for your subsequent weight loss visit
$30.00Edit
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Chronic Disease Care with PriscillaHypertension, Diabetes on oral medication, Hypothyroidism previously diagnosed, hyperlipidemia
$50.00Edit
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Acute Illness with Priscilla Pink eye, Sinus Infection, quit smoking, motion sickness, UTI females only, athletes foot, and dandruff
$40.00Edit
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Medication Refill with PriscillaPlease select the # of medications that you would like to refill. You’ve taken your medication within the past 6 months without adverse effect
$10.00Edit
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Subtotal: $0.00
Preventive Services with PricillaWellness and travel
$40.00Edit
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Enter Coupon
Total cost $0.00
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Step 3: Complete Consent Forms

Last step! Please complete the following 4 notices. At the end of the notices, you will be asked to provide your signature.

In order for our nurse practitioner to treat you or make lab or prescription orders, we need to receive the next 4 consents from you.

Complete the following consent forms to receive care from Priscilla Agali referred to as "The Practice and Clinician" in the following documents.
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General Consent* This field is required.
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Telehealth Consent* This field is required.
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Financial Policy & Disclosure* This field is required.
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Patient Health Information Consent* This field is required.
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In the future, our practice will be taking insurance. Which insurance do you have, so that we can know once we get in network?
No insurance; I pay cash for my care
Medicare
Medicaid
BCBS or Anthem
United Healthcare
Humana
Cigna
Aetna
Other
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Take photo of your insurance card
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Please provide your signature* This field is required.Sign with your finger!
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Please provide today's date* This field is required.
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