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:*

Date

Will you be using Insurance or Self-Pay? *

Insurance Card, if using insurance. (front and back):

Browse Files

REASON FOR YOUR VISIT*

Allergies*

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

Before you finish this form, we wanted to share the exciting news. My Virtual Physician now has its own app.

Google Play store:

https://play.google.com/store/apps/details?id=com.lifehealthwalletusa.lifehealthwalletusa&hl=en&gl=US

Apple App store

https://apps.apple.com/us/app/my-virtual-physician/id6474680347

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