Acute Care Visit Form

Acute Care Visit Form
Patient Name

First NameLast Name
Birthdate

MonthDayYear
Date
Phone Number
Email
example@example.com
How would you like to speak with a practitioner?

VideoPhone
Select an appointment type

Cough/Cold/SinusImpetigoEarPink EyeRingwormSwimmers EarSore ThroatCold SoreYeast InfectionAllergiesBacterial VaginosisPoison IvyUrinary Tracy InfectionDeer Tick BiteBug bitesErectile DysfunctionSTIsWeight LossPrescription RefillOther
My Products
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Acute Care ConsultationConsultation Fee for Virtual Care Services
$40.00



Weight Loss Management - 15 min ConsultConsult for weight management, intro to what we offer and to help answer questions for you
$25.00



Prescription Refill VisitManagement of long-term prescriptions and refills for chronic conditions, etc
$75.00



Subtotal

$0.00

Tax

$0.00

Total

$0.00
All payments include a 1.8% State of Minnesota Provider Tax.

After payment is submitted, DO NOT FORGET to come back to this page and submit your appointment request to finalize your request.
Acute Care Visit Payment Link

Weight Loss Management 15-min Consult Payment Link

Prescription Refill Visit Payment Link
Once your submission form and payment have been received, we will reach out to you for a visit or send you a scheduling link, within two hours of submission between 7a-8p CST. If received after 8p we will respond by the next morning, 7 days per week.

If you have an urgent medical need or life threatening injuries or concerns, you should report to your local Emergency Department.
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