Teleconsultation Appointment Request Form

Teleconsultation Appointment Request Form

Fill the form below and we will get back soon to you for more updates and plan your appointment.
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Have you ever applied to our facility before?*

YesNo
Which service do you want to make an appointment for?*
Symptoms: What do you feel? How often do you experience this? *
Preferred Appointment Date *
For teleconsultations, payments are made easily online through e-wallets. Bank transfers are also accepted.
Once the payment has been settled, RMED will send you a secure email with Zoom instructions prior to your e-consultation session.

Please send the proof of payment (e.g. screenshot of payment confirmation)
Cancelof
Should be Empty: