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. Thank you for including us in your care.
Today's date:

Month Day Year
Date
Name

First Name Last Name
Birth Date

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

Yes No
Do you have a co-pay or co-insurance?

Yes No
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/Chills Unexplained change in weight Fatigue/Malaise/Generalized weakness Headaches/Migraines Dizziness Sinus Pain/Pressure/Discharge Vision changes Wheezing/Chronic Cough Shortness of breath Chest pain, pressure or tightness Swelling of hands/feet/ankles Nausea/Vomiting Abdominal pain Heartburn Constipation or diarrhea Stiffness/Pain in joints/muscles Joint swelling Bleeding/Easy bruising Excessive urination Excessive thirst/hunger Hot flashes Painful/Bloody urination Difficulty urinating/Night-time urination Urinary incontinence (leakage) Vaginal discharge or pain Rash Anxiety/Panic Attacks Depression Insomnia/Problems with Sleep Thoughts 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