Schedule a Visit with Emer Gaite

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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 California* This field is required.
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We're so sorry, but this provider only sees patients in California 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.
First Name
Last Name
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What is your date of birth?* This field is required.
Date
Year
Month
Day
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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.
Please enter a valid phone number.
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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.
example@example.com
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Please provide your address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Nauru
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Netherlands
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Nigeria
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Poland
Portugal
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Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
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Saint Lucia
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Isle of Man
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Western Sahara
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Other
Country
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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
Other
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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.
Huge
Large
Normal
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Ok
Ok
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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
Virtual visit with XYZNon-Emergent Medical problems will be assessed and treated through a telehealth visit
$49.00+Edit
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Total cost $0.00
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Credit Card Number
Security Code
Card Expiration
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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 Shila Robbs, 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
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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.
Date
Year
Month
Day
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