• Telemedicine Registration Form

• 
  
• Date
• Patient Name
• Date of Birth
• Address

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• Phone

  --
• Email
• 
  

• ---

• Insurance

• 
  
• Insurance Provider
• Name of Subscriber
• Group Number
• Contract Number
• 
  

• ---

• Visit Information

• 
  
• Name of Primary Physician
• Phone

  --
• Reason for Today's Tele-Visit

  illness Injury Office Visit
• Briefly describe your medical issue.
• When did the illness/injury begin?
• Have you seen a doctor in person prior to today's visit?

  Yes No
• Have you used our telemedicine service before?

  Yes No
• Date of Service (approximately)
• Signature