Triple O Medical Form

1
What is your full name?* This field is required.As it appears on your insurance.
First Name
Last Name
2
Best phone number to reach you* This field is required.We’ll use this number to contact you regarding your request.
Please enter a valid phone number.
3
What insurance plan do you currently have?* This field is required.This helps us verify coverage and guide you appropriately. If you DO NOT have insurance, please write “No insurance.”
4
Please upload a photo of your insurance card (Optional)(Front and back, if available) Your information is protected and securely reviewed by our medical team. If you prefer not to upload your card here, we can collect this information by phone when we contact you.
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Max. file size: 10.6MB
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5
Who is your primary care doctor?* This field is required.Please include the name and phone number, if available. This helps us determine whether a referral is required.
6
What is the main reason you would like to see an infectious disease specialist?* This field is required.Please describe any symptoms or diagnosis related to your visit.
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Large
Normal
Small
Ok
Ok
7
Do you have medical records or blood tests related to this concern?* This field is required.Medical records are helpful for our team to better understand your situation.
Yes
No
Not Sure
Should be Empty: