Clone of SimoneRx - Appointment Form

1
Age confirmation* This field is required.SimoneRX provides care to patients 18 years of age and older. Please confirm to continue.
I am 18 years of age or older
2
What state are you currently located in?* This field is required.We can only see patients in states where Simone is licensed.
Please Select
Please Select
Georgia
California
New Hampshire
3
Date of birth* This field is required.
Month
Day
Year
4
What is your full legal name?* This field is required.
First Name
Last Name
5
Gender* This field is required.
Please Select
Please Select
Female
Male
Non-binary
Prefer to self-describe
Prefer not to say
6
Phone number* This field is required.
Please enter a valid phone number.
7
Email address* This field is required.
example@example.com
8
How should we follow up to confirm your appointment? (Select all that apply.)* This field is required.
Email
Phone Call
Text Message
9
What's the best time of day to reach you?* This field is required.
Please Select
Please Select
Morning (8am–12pm)
Afternoon (12pm–5pm)
Evening (5pm–8pm)
10
Which chronic condition are you seeking support for? (Select all that apply.)* This field is required.
Hypertension (high blood pressure)
Type 2 Diabetes
High cholesterol
Thyroid disorder
Asthma
Acid reflux / GERD
Other
11
Briefly tell us what's bringing you in today* This field is required.Current symptoms, any recent labs or readings, and what you are hoping to address.
12
Please review and check ALL boxes to continue* This field is required.
I have received and reviewed the Notice of Privacy Practices (HIPAA) at simonerx.com/privacy-policy
I consent to receive care through telehealth (video or phone) and understand its benefits and limitations
I understand this is an appointment request, not a confirmed appointment. The SimoneRX team will follow up to confirm and schedule
I certify that the information I have provided is accurate and complete to the best of my knowledge
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