New Patient Signup Documents
This is the basic demographic information we need to begin the onboarding process
Patient Information
First Name
*
Last Name
*
Primary Phone
Cell Phone
*
Email
*
example@example.com
Preferred Language
Please Select
English
Spanish
Other
Medication History Consent (Allows TeleMeMD to access your medication history over the past year)
*
Yes
No
Date of Birth
/
Month
/
Day
Year
Date
What is Your Birth Sex
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Marital Status
Please Select
Single
Married
Divorced
Widowed
Emergency Contact Information
Emergency Contact
*
Emergency Contact Number
*
Please enter a valid phone number.
Emergency Contact Relationship
*
Primary Physician Contact Information
Primary Physician (PCP)
PCP Address
PCP Email
example@example.com
PCP Phone
PCP Fax
Pharmacy
Preferred Pharmacy
Pharmacy Phone Number
Insurance Information
Please note that TeleMeMD does not accept insurance for payment. Insurance information is being collected for referral, laboratory and diagnostic testing purposes
Do you currently have health insurance?
Yes
No (You may skip to the "Subscription Signup" Section)
Name of Insurance Company
Address of Insurance Company
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance ID Number
Group Number
Insurance card photo (Front of card)
Insurance card photo (Back of card)
Subscription Signup
How Many Adults Do You Wish to Enroll (18 years if age or more)
*
How Many Children Do You Wish to Enroll? (3 months - 17 years of age)
*
Choose Your Service Plan
*
Subscription (You will be billed monthly)
Fee for Service (You will only be billed for services rendered)
Preview PDF
Submit
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