Impact Health & Wellness Clinic – Appointment Request
Telehealth Primary Care • Weight Management • Chronic Disease Management
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Appointment Date and Time
*
Type of Visit
*
Please Select
One-Time Telehealth Visit – $75
Chronic Condition Management – $85
Medication Management – $75
Lab Review Appointment – $50
Prescription Refill Visit – $55
Weight Management Initial Visit – $125
Weight Management Follow-Up – $85
PAYMENT POLICY
*
Reason for Visit
*
Wellness Membership
Please Select
Enroll for $50/month
Premium Care Membership
Please Select
Enroll for $99/month
MEMBERSHIP AGREEMENT
I understand that membership plans are monthly subscriptions and will be billed recurring each month. I acknowledge that membership benefits apply after enrollment and payment.
PAYMENT POLICY
*
I understand that payment is required prior to scheduling my appointment. My appointment is not confirmed until payment is received.
INTAKE POLICY
*
I understand that all intake forms must be completed prior to my appointment.
EMERGENCY DISCLAIMER
*
I understand this form is for appointment requests only and not for medical emergencies. If this is an emergency, I will call 911 or go to the nearest emergency room.
EMERGENCY DISCLAIMER
*
Need immediate assistance? Call us at (601) 236-1800 Email:admin@impachealthclinic.com
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