SportsMD VUC Form

Virtual Care Appointment Request Form

Please fill the form out below and make sure you scroll through the entire form. Once completed, you will receive a confirmation email and text message with information on how to join your appointment.
Medical Emergencies should Call 911 or visit the nearest Emergency Room
Patient Information
Name*

First NameLast Name
Email*
example@example.com
Mobile / Cell Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
What is your primary/preferred language?*
Consent for Treatment of a Minor

(Hereinafter “I”) seek the healthcare related services of OrthoLive Medical Group (“Practice”) for myself, my child, or otherwise an individual over whom I am empowered to provide such authorization, and I hereby voluntarily consent to the provider (“Provider”) and/or any other healthcare providers and staff associated with Practice to provide me/my child/minor with healthcare related advice, basic treatments, medical and/or diagnostic procedures. I hereby consent to their participation in the care and treatment of me/my child and the sharing of their information upon any referral to another healthcare provider. I am here for my own purposes and not on behalf of any third-party. I understand that I am a participant in the decision-making process, and I am free to decline advice, services, or treatments at any time. I agree to bring to the attention of Practice’s clinical staff, if, at any time, I have any lack of understanding of such risks, benefits, and alternatives, and inquire of clinical staff for further explanation until I have a full understanding before giving consent to any procedure or treatment. I acknowledge that some or all of the healthcare professionals performing services for the Practice are independent contractors and are not agents or employees.
Guardian Name

First NameLast Name
Guardian Email
example@example.com
Guardian Mobile / Cell Number

Area CodePhone Number
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Current Location (Complete if different from Home Address)

Street Address

Street Address Line 2

CityState

Zip Code
Injury Information

How urgent is your injury? (1 = Not Urgent | 2 = Urgent | 3 = Medical Emergency)*

	1	2	3

1 is Not Urgent, 3 is Emergency

If exact Injury Date is unknown, estimate how long you have been dealing with the injury and select a date around that time.
Injury Date*

MonthDayYear
Did this injury happen at work?*

NoYes
Name of your Employer
Body Part*
Side of Body*
Chief Complaint*
Injury Description:*
Please describe your injury, how it happened, pain level, and so on. The more information you can provide the better our treatment.

How is the pain feeling? (1 = Better | 2 = Steady | 3 = Getting Worse)*

	1	2	3

1 is Better, 3 is Getting Worse

What is the pain level? (1 = Low | 5 = Moderate | 10 = High) *

	1	2	3	4	5	6	7	8	9	10

1 is Low Pain, 10 is High Pain

Current Treatment
Please describe any treatment you are doing currently.
You may upload images of the injured body part below.
Pictures or Images of Injured Body Part

Browse Files

Cancelof
Complete the information below to schedule a Virtual Visit.
Payment
All visits are in English. If translation/interpreter is required, select appropriate service and indicate your primary language.
Are Translation Services Required?*

NoYes

Please select services below: *

SportsMD Injury Triage Telehealth Visit$29.00

Virtual Visit

Translation Service$25.00

Translation Services

Total $0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Date and Time of Appointment
Practice
Today

MonthDayYear
Date
MinorDOB

MonthDayYear
Date
Should be Empty:

Virtual Care Appointment Request Form

Complete the information below to schedule a Virtual Visit.