Telemedicine Visit Basic Form

Current Location:*
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Current Age (Years): *
What was your gender at birth?*

FemaleMale
Height (inches)*
Weight (lbs)*
Email*

Confirmation Emailexample@example.com
Phone Number*
Please enter a valid phone number.
Home Address
Legal Guardian's Name:*

First NameLast Name
I attest that I am the legal guardian and consent to the treatment of the minor listed above. *

Powered by Jotform SignClear

TERMS OF SERVICE
I am NOT covered by Medicare or MedicaidI am covered by Medicare or Medicaid and I agree to the terms of the Advanced Beneficiary Notice (ABN) below
Advanced Beneficiary Notice

Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor.

You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:
- Severe or unusual chest pain
- Severe shortness of breath
- Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
- Thoughts of harming yourself or others
ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*

Yes, I am having an emergencyNo, I am NOT having an emergency

Do you have any medication allergies?*

YesNo Known Drug Allergies (NKDA)
Please list your medication allergies:*
Are you currently taking any medications?*

YesNo
Please list your current medication and dose below (i.e. Wellbutrin XL 150mg tab)*
Are you pregnant?*

YesNoNot sure
Are you breastfeeding?*

YesNo

Would you like to add any additional information or questions for the provider to see?*

YesNo
Add additional information below:*

My Products

Telemedicine Visit

$39.00

Enter coupon

Total

$0.00

TERMS OF SERVICE