Telemedicine Appointment Request Form
Let us know how we can help you! We are covering MN, WI, IA, KS, TX, IL
Full Name
First Name
Last Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select applicable need
USCIS Citizenship Exam Disability Exemption Consultation ( Medical Records Needed)
Focussed Primary Care Consultation
Immigration Medical Exam
Weight Loss Consultation
medical consultation or service in your home or office ( wellness hydration, weight loss, physical therapy, etc )
Semaglutide Prescription
Tirzepatide Prescription
Upload your insurance card or relevant medical information
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