Telehealth Patient Registration Form

Patient Information

33%

Patient Registration Form

We know your time is valuable. That’s why we’ve streamlined our online registration to be quick and convenient

Sex*

Delivery Address (for medication shipments)

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Medical & Prescription Details

67%

Please select

Do you have any allergies?

Clear choice

Yes

No

If yes, please list all allergies separated by commas

Please list any medications you are taking. Don't forget to include non-prescription drugs & medications.

Any additional information you'd like to share with telehealth provider (optional)

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Consent & Acknowledgements

100%

Consent to Share Information with the Telehealth Provider

I consent to share my personal, medical, and contact information provided in this form with the designated telehealth provider. I understand that this information will be used solely to assess my healthcare needs and facilitate my telehealth consultation, and that it will be handled in accordance with all applicable privacy and confidentiality regulations.

Acknowledgement of Privacy Policy

I have read and agree to the Privacy Policy.

Signature of patient, guardian/parent

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