Telehealth Returning Visit Form

Telehealth Returning Visit Form

All telehealth patients must be existing clinic patients, and have been seen previously in our clinic. Please complete this form if instructed by our staff, along with any copay or deductible amount due. There is a $50 no show charge if not attended or cancelled < 24 hours before appointment. Thank you for including us in your care.
Today's date:

MonthDayYear
Date
Name

First NameLast Name
Birth Date

MonthDayYear
What is the reason for your visit today?
Any changes to your insurance or address?
Do you have a deductible?

YesNo
Do you have a co-pay or co-insurance?

YesNo
Copays and deductibles are due at the time of service. How much is your copay or deductible?
Check the symptoms that you have experienced in the PAST 2 WEEKS

Fever/ChillsUnexplained change in weightFatigue/Malaise/Generalized weaknessHeadaches/MigrainesDizzinessSinus Pain/Pressure/DischargeVision changesWheezing/Chronic CoughShortness of breathChest pain, pressure or tightnessSwelling of hands/feet/anklesNausea/VomitingAbdominal painHeartburnConstipation or diarrheaStiffness/Pain in joints/musclesJoint swellingBleeding/Easy bruisingExcessive urinationExcessive thirst/hungerHot flashesPainful/Bloody urinationDifficulty urinating/Night-time urinationUrinary incontinence (leakage)Vaginal discharge or painRashAnxiety/Panic AttacksDepressionInsomnia/Problems with SleepThoughts of harming self or others
Anything else you'd like us to know?

Pay for your telehealth visit:

Copay or deductible amount$1.00

Change quantity to equal your copay or deductible amount due prior to your appointment. Please round up or down to the nearest dollar.

change quantity to equal copay/deductible

Total $0.00