Teledoc Appointment
Please fill the form below to book an on-demand Teledoc Appointment
Patient Details
Allow us to know about you.
First Name
Middle Name
Last Name
Phone
Email Address
Date of Birth
Gender
Male
Female
Others
Preferred Method Of Communication
Phone
Video Call
Email
Appointment Details
Let's now setup an appointment for you.
Reason of Appointment
Kindly describe the reason of appointment in detail.
Preferred Appointment Time
Hours
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Minutes
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Preffered Appointment Date
Preferred Appointment Type
Phone
Video Call
In-Person
Medical History
Let us understand your medical history and records for a better consultation.
Current Medication (If Any)
Kindly share the Name & Dosage of current medication. (If Any)
Allergies (If Any)
Kindly share the allergies (if any).
Primary Care Physician Name
Primary Care Physician Phone
Past Medical History
Briefly describe any relevant past illnesses or conditions.
Insurance Information
Let's setup your coverage with us to save your hard earned cash.
Provider Name
Insurance Group
Card ID
Insurance BIN
Insurance PCN
Emergency Contact Information
Please share the contact information for the person we should contact in case of emergency.
Emergency Contact Name
Emergency Contact Phone
Consent
*
Yes, I agree with the
Telehealth Consent
,
HIPAA
and
Term & Conditions
.
Submit
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