Mira Appointment Request Form

Appointment Request Form

Thank you for requesting a Mira appointment. Please fill out this secure, confidential form, and our scheduling team will contact you to set up an appointment.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Mira App Email (if different from above)
example@example.com
Mira Order Number*
Order Number
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please enter your preferred language below or type "decline."*
What state will you physically be in at the time of your appointment?*
Preferred Pharmacy (include address)*
Reason for Visit: be as specific as possible.*
Do you plan on using your insurance for the visit with the physician or self-pay?*
If you have insurance, upload a photo of your insurance card (front & back)*

Cancelof
By signing below you are agreeing to the following terms: If opting for self-pay or your insurance is out of network with our group, a fee of 99.99 for a 30 minute appointment, or a fee of 199.99 for a one hour appointment will apply.*

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Before you finish this form, we wanted to share the exciting news. My Virtual Physician now has its own app. Available now on Android phones/tablets from the Google Play Store. Click here to download https://play.google.com/store/apps/details?id=com.lifehealthwalletusa.lifehealthwalletusa&hl=en&gl=US
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