Schedule a telehealth visit with Trace Owens

1
Step 1: Provide your contact information and select your appointment date & time
2
Please confirm that you reside in onfe of the following States: AZ, CO, FL, HI, ID, IA, KS, ME, MD, MT, NE, NV, NH, NMNY, ND, OR, RI, SD, VT, VA, WA, WY.* This field is required.
YESNO
3
Oh no!

We're so sorry, but this provider only sees patients in the States previously listed.

Please cick here to return to our website to find a nurse practitioner in your state.
4
What is your legal first and last name?* This field is required.
First Name
Last Name
5
What is your date of birth?* This field is required.
Date
Year
Month
Day
6
What is your preferred gender?* This field is required.
Male
Female
Non-binary
7
To order prescriptions, refills, labs, or referrals, we will need your Social Security Number. If you need any of these services, please provide this information.
8
What is the best cell phone number to reach you at?* This field is required.
Please enter a valid phone number.
9
What is the best email to reach you at?* This field is required.This is the email that we will send the telehealth link to.
example@example.com
10
Please provide your address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
What is the reason for your appointment?* This field is required.Select all that apply!
No appointment, just registering.
I'm sick!
Preventive visit
New medications
Refill a prescription
I need labs ordered
I need a referral
Other
12
What is the preferred pharmacy that you use?Please provide the address of the pharmacy in the event that you need a prescription or a refill.
Huge
Large
Normal
Small
Ok
Ok
13
Select your appointment time* This field is required.
14
Step 2: Select your service and make payment* This field is required.Enter your credit card information below. You're half way done!
prevnext( X )
My Bag
0
My Bag
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
Great Product Name
$20
Quantity:1
Size:Small
RemoveEdit
ORDER SUMMARY
Total costUSD
Medication Refill with Trace OwensJust for medication refills!
$49.99+Edit
Back
Telehealth visit with Trace Owens
$49.99+Edit
Back
Men's Health Visit with Trace Owens
$89.99+Edit
Back
Enter Coupon
Total cost $0.00
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
15
For telehealth appointments, how would you prefer that we contact you?
Email me a link to join the visit
Text me a link to join the visit
16
In the event that you need labs, prescriptions, or imaging ordered, you can use your insurance. Do you currently have insurance?
YESNO
17
Please take a picture of the front of your insurance card.
18
Please take a picture of the back of your insurance card.
19
Step 3: Complete Consent Forms

Last step! Please complete the following 4 notices. At the end of the notices, you will be asked to provide your signature.

In order for our nurse practitioner to treat you or make lab or prescription orders, we need to receive the next 4 consents from you.
20
General Consent* This field is required.
21
Telehealth Consent* This field is required.
22
Financial Policy & Disclosure* This field is required.
23
Patient Health Information Consent* This field is required.
24
Please provide your signature* This field is required.Sign with your finger!
Clear
25
Please provide today's date* This field is required.
Date
Year
Month
Day
26
Last Question! Are you willing to spend 3 minutes of your time completing an anonymous survey to help us improve the care we provide patients? * This field is required.
YESNO
Should be Empty: