Telehealth Patient Triage

Telehealth Patient Triage

Please complete this form to help us address your prescription or medical needs and process your payment.
Consent of Non-secure Forms of Electronic Communication

Electronic communication, via email, FaceBook/Instagram direct messaging and text, between you and the health care provider may not be secure. By signing below, you are acknowledging that you realize that email, direct messaging, and text communication does not provide a completely secure means of communication. While your health care provider will take reasonable efforts to protect your confidentiality, there is some risk that any protected health information contained in email, direct messaging or text may be disclosed to or intercepted by unauthorized third parties.

Use of more secure communications, such as phone or fax, are always an alternative that are available to you if you elect to not give consent to the following forms of communication.

I give permission for my health care provider to contact me using non-secure methods regarding reminders, scheduling, or other relevant matters, and I understand the risks involved.

I understand that all the laws that are protecting my privacy of medical history or information are also applied to telemedicine practices.
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth

MonthDayYear
Date
What is the main reason for your visit today?

Other
Please list any allergies
Tell me more about how I can help you today!
Insert a photo if needed

Cancelof
Pharmacy Name and Location (for prescription call-in)

Payment

Telehealth Consultation

Fee for telehealth triage and prescription service.

$75.00

Total

Credit Card

Should be Empty: