Medical Patient Intake Form

Patient Application Form
LOHS Telemedicine Care is Available

Monday - Friday 8am - 5pm for ages 15 and above.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender*

FemaleMale
Email*
example@example.com
Phone Number*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Information*
Emergency Contact Information
Drivers License (Front)*
Drivers License (Back)
Check all symptoms that apply

Minor cut, burn, or woundMinor injury, infection, or irritationSevere cold and Flu SymptomsRashSprainMuscle aches and painsPersistent FeverAllergiesSevere earacheUpset stomachUrinary tract infection
Chief complaint today:*
Past Medical Histoy:*
List out all current medication*
List out allergies*
Have you been treated by LOHS Telemedicine Care before ?

YesNo
Appointment Options (Select Only One)*

First Appointment AvailablePreferred Date and Time (Select Below)
Appointment
Where will the DoxyMe Video Chat Link & Billing Link be sent? (no app downloads needed)*

Emailed to the email address aboveTexted to the phone number above
Please Read Carefully
- If your Telemedicine Application is apporved by the Provider, the payment link will be sent next.
- You will be notified immediatley if the Provider feels the compliant is needing a higher level of care than Telemedicine services can provide.
Date of Submission*

MonthDayYear
Date
Time of Submission*

Hour Minutes

AM/PM Option
Signature*

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LOHS Telemedicine Care is only available at the private pay rate of $75.00/per appointment.

No insurances are accepted at this time. See Terms and Conditions above.
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Patient Application Form