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)

CityState

Zip Code
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
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
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