MVP Book an Appointment Form (For people using the chat bot)

Your Name*

First NameLast Name
Your home or mailing address*

1234 Main St.

Apartment, Suite, etc. (optional)

City

Zip Code
State of your current location*
Sex assigned at birth

MF
Your Phone Number*

Area CodePhone Number
Your Email*
example@example.com
Date of Birth:*

MonthDayYear
Date
Will you be using Insurance or Self-Pay? *
Insurance Card, if using insurance. (front and back):

Browse Files

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REASON FOR YOUR VISIT*

Need a primary care doctorJust need refill of prescriptionI need a doctor note or letterInterested In the CAYA diaphragmWeight Loss consultNeed to consult with a Gynecologist (birth control, menopause, abnormal bleeding, STD etc)Need a shaving waiver letterNeed to consult with an endocrinologistNeed to consult with a pediatricianNeed to consult with a dermatologistNeed controlled medications for ADHD (note--we only offer this service in Las Vegas)Need a doctor to sign release form for Fresh Frozen Sperm to be shipped to my homeI am attending the SANU postpartum retreat and have questions for a doctorNone of the above.
Allergies*

PenicllinSulfa drugsIodine/shellfishMorphineACE Inhibitors(e.g Losartan)otherI have no allergies to medications
What is the address of your preferred pharmacy*

Street Address

Street Address Line 2

CityState

Zip Code
Is there anything going on in your life right now—like problems with housing, food, bills, or getting to appointments—that makes it harder to take care of your health

YESNO
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.
E-CHECK IN / ONLINE DIGITAL SERVICES CONSENT AND DISCLOSURE FOR INSURANCE PAYING PATIENTS

Our practice offers e-check in services (also called "online digital evaluation and management services") to established patients. These services allow you to communicate with your provider through our secure patient portal for medical questions or concerns.

What You Need to Know:

These services will result in charges to you. E-check in services are billed using CPT codes 99421-99423 and are subject to your insurance copayment, coinsurance, and deductible, just like an office visit. The charge is based on the cumulative time your provider spends reviewing and responding to your inquiry over a 7-day period.

How it works: You initiate communication through our patient portal with a medical question or concern. Your provider will review your message and respond. This service is separate from brief administrative communications (like appointment scheduling or prescription refills).

You can decline: You are never required to use e-check in services. You may decline these services at any time and choose to schedule a regular office visit instead.

CONSENT:

By submitting below, I acknowledge that:

I have been informed about e-check in services and understand they may result in charges

I consent to receive e-check in services when I initiate communication through the patient portal

I understand these services are subject to my insurance copayment, coinsurance, and deductible

I can decline these services at any time and request an office visit instead
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