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*
Email*
example@gmail.com
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Do you have any allergies?*

YesNo
Please provide the list of your allergies below*
Do you use any medications?*

YesNo
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?*

YesNo
What is your requested medication name and dose?*
Do you have a preferred pharmacy for your prescriptions?*

YesNo
Would you like to send us a photo or file to study before our visit?

Cancelof
Receive text reminders for your Care365 appointment?*

YesNo

Virtual Health Appointment Non-Refundable Fee

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

$70.00

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Appointment for USA Residents