Physician 360 Telehealth Consult
As many patients have used this service in the past, we can refer you to a consult with Physician 360 who has helped patients who may not have a provider but would like to speak to one via telehealth. Please fill out the information below and you will receive next steps via email. To make the process easier, the email their team sends you for next steps will also be included in the thank you page/email when you submit this form. Use this link for your initial consult & any follow-ups you may need. ***Physician 360 does not do prior authorizations for prescriptions nor fill any controlled medications***
Patient's Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
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Email
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Preferably non-comcast.net email addresses as Comcast has been filtering our emails or sending them to spam. If it is a comcast.net email address & you sign up, if you see the THANK YOU page after submitting, thats the same information that would get emailed to you.
Purpose
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Anemia
Birth Control
Coronavirus
Ear Infection
Erectile Dysfunction
Flu
Hair Loss & Regrowth
High Cholesterol
Longevity (Anti-Aging)
Strep Throat
UTI
Weight Loss
Women's Health
Other
Purpose of Visit
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Any thing you'd like us to pass along to the provider from Physician 360 that they should know about you or about your consult request? Put anything you'd like us to share with them. You can go further into detail on the call but this is to pre-face your call.
Signature: By signing below I give Skippack Pharmacy consent to share information from the Interest Form I filled out & data above with the Physician 360 provider's team. Physician 360 providers will utilize this information along with information I input when creating a profile/making a payment on the Physician 360 system in the next steps. In the event I need any support for Physician 360, I will reach out to their team directly at support@myphysician360.com or by calling them: 360-861-6199.
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Submit
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