Thank you for verifying your identity and providing the information necessary for Dr. Sartin to review your case.
By submitting this form below, you are authorizing Dr. Sartin to review your records and meet with you via video to complete the FMLA examination process.
You will receive an email confirmation after submitting this form with further instructions. Please make sure to check your spam folder if you do not see an email from us after this form has been submitted.
Upon submission of this form, you will be directed to the payment link for the appointment fee of $50.00. This is to lock in your video visit with Dr. Sartin.
The remaining service fee of $149.00 will be invoiced upon completion of the video visit. Once the payment for the remaining balance is received, you will be sent an email notification when the completed form is uploaded to your secure patient portal. Our aim is to have the form completed within 3 days of the video visit. Often, the form may be completed sooner.
If you need any assistance, please contact us at contact@mydrsnote.com.
Please click "submit" to complete the form request and be routed to the payment page.