Telehealth Session Check in
At Requested Appointment Time or Before, Or Request A Session Same Day
Pre-Payment Authorization Form & Telehealth Check in
Please read the following carefully. By Paying Below You Confirm Your Appointment for Telehealth, and Front Desk will transfer you to the approriate waiting room.
Please Note*
Choose a time Suitable for you, and Clinician's hours are listed Below.
Faisal Rafiq MD
Hours of Telehealth Monday- Thursday 4:30pm-5:15pm
Mohammad Rafiq Faiz, PA-C
Hours of Telehealth Monday- Thursday 9am-6:45pm
Date and Time of Appointment
*
/
Month
/
Day
Year
Hour Minutes
AM
PM
AM/PM Option
Patient Name:
*
First Name
Last Name
Email
*
example@example.com
Mobile Phone Number
*
We will text this number your for your session
Payment Required
*
Charge My Card on File for my Fee
Payment is Required
No Payment Required
Subscription Member (Prior Sign Up Required)
Copay or Private Pay
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next
( X )
USD
Payment Amount
Payment Details
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
After Your Session with Regards to Your Followup Appointment
*
Please Schedule and Text me my Automated Monthly Followup
Please Text Me So I can Choose My next Followup Date
Any Comments or Concerns for Session or Pharmacy Changes List Below: (optional)
Start Session
Should be Empty: