Clone of Telehealth Appointment

Telemedicine Consultation

All information is strictly confidential & HIPAA protected.
Full Name*

First Name Last Name Suffix
Birthdate*

MonthDayYear
Date (YOU MUST BE 21+)
Email*
example@example.com
Social Security Number*
We must have this information to see you beginning November 3, 2025
Phone Number*
Please enter a valid phone number. This is how we will call you to set up your video visit.
Current Address (MUST BE A CURRENT VIRGINIA RESIDENT & HAVE A NON-EXPIRED CURRENT VIRGINIA ID - ADDRESS PROVIDED MUST MATCH ADDRESS ON THE VIRGINIA ID)*

Street Address

Street Address Line 2

CityState (MUST BE VA)

Postal / Zip Code
What is your medical diagnosis?*
What medications do you take?*
What medications do you take? Include over-the-counter medications, vitamins, and supplements
What are your allergies? *
What are your allergies
Please tell us about your past experiences, current knowledge level, and if you are new or not. We are here to help educate you on the risks and benefits during your Telemedicine Visit.*

I CERTIFY THAT I AM A CURRENT RESIDENT OF VIRGINIA & HAVE AN UNEXPIRED VIRGINIA ID (driver's license or state ID).*

YES, I am a Virginia Resident and I have an unexpired Virginia IDNO, I am not a Virginia Resident and/or I do not have an unexpired Virginia ID (IF YOU CHECK THIS BOX WE CANNOT SEE YOU. PLEASE CALL OUR OFFICE TO DISCUSS OPTIONS).
Signature*

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My Products

Telemedicine VisitThis is payment for a telemedicine consultation. By paying, you understand that services are not guaranteed. We will evaluate every patient equally and fairly.

$80.00

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Total

$0.00

Payment Methods

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Telemedicine Consultation

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