USA Patients

Appointment for USA Residents

Fill out the form below, and we’ll contact you to schedule your appointment.
Name

PrefixFirst NameMiddle NameLast Name
Date of Birth

DayMonthYear
Gender
Phone Number
Format: (000) 000-0000.
Email
example@gmail.com
Address

Street Address

Street Address Line 2

CityProvince

Postal Code
Do you have any allergies?
Please provide the list of your allergies below
Do you use any medications?
Please list the names, strengths, and dosages of your medications, along with how you take them, in the space below.
What is the primary reason for your visit to the doctor?
Please explain as detailed as possible, explain if it is a refill request, what medication, what condition, etc.
Is there a specific medication you would like to request?
What is your requested medication name and dose?
Do you have a preferred pharmacy for your prescriptions?
Would you like to send us a photo or file to study before our visit?

Cancelof
Receive text reminders for your Care365 appointment?

Virtual Health

After payment, we’ll call to finalize your appointment (same-day or preferred time).

$70.00

Subtotal

Tax

Total

Appointment for USA Residents