Telemedicine Consultation
All information is strictly confidential & HIPAA protected.
Full Name
*
First Name
Last Name
Suffix
Birthdate
*
-
Month
-
Day
Year
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 (ADDRESS MUST MATCH YOUR VIRGINIA ID).
*
Street Address
Street Address Line 2
City
State (MUST BE VIRGINIA)
Postal / Zip Code
What is your medical diagnosis? Please include date(s) of diagnosis
*
Please Upload any medical files and proof of medical diagnosis here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
What medications do you take?
*
What medications do you take? Include over-the-counter medications, vitamins, and supplements
I CERTIFY THAT I do not take and that I AM NOT CURRENTLY PRESCRIBED any controlled medications such as stimulants (ie ADDERALL, RITALIN, or similar), benzodiazepines (ie XANAX, CLONAZEPAM, or similar), sedatives (ie Ambien or similar), gabapentin, or opioids (ie Percocet or similar).
*
YES, I am currently on one or more of these medications. I will call first to discuss
No, I am not on any of these. I also acknowledge that if I am not truthful on this application our medical provider will cancel this consultation request
I am not currently taking Suboxone, Methadone, Buprenorphine, or any other medication-assisted treatment (MAT), and I have never taken any of these in the past.
*
I am not currently, nor have I ever been, on any of these types of medications
I am currently on one of these medications or have been on one or more within the past three years. I will call first to discuss
What are your allergies?
*
What are your allergies
Please share your past experiences, current knowledge level, and whether you’re new to this. During your telemedicine visit, we’ll help you understand the risks and benefits.
*
Back
Next
I CERTIFY THAT I AM A CURRENT RESIDENT OF VIRGINIA & HAVE AN UNEXPIRED VIRGINIA DRIVERS LICENSE.
*
YES, I am a Virginia Resident and I have an unexpired Virginia license
No, I am not a Virginia resident and/or do not have a valid Virginia ID
Take Photo of Your Virginia Drivers License To Upload Here
*
Signature
*
My Products
prev
next
( X )
Telemedicine Visit
This 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
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
Continue
Should be Empty: