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Appointment Form

Appointment Details

Scheduling with

Condition or visit reason

Disclaimer - Mnemonic
If you select a different condition, you will be required to choose a new location and a new date & time.
Input - Condition
Label
Please enter a valid condition.
Disclaimer - Visit reason
This reason for visit requires a referral from a doctor.

Visit type

Disclaimer - Visit type
If you select a different visit type, you may be required to choose a new date & time.
Input - Visit type
Please select a valid visit type.

Location

Telehealth visit box title
Telehealth visit
Telehealth visit text box
Telehealth allows you to be seen via a computer or mobile device. You will be sent a link upon scheduling your appointment.
Disclaimer - Location
If you select a different location, you may be required to choose a new date & time.

Day & time

Patient Information

Logged in as

   
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and log in with another account.

Patient Information

Full name * (Optional)
Input - First name
Label
Please enter a valid first name.
Input - Last name
Label
Please enter a valid last name.
Date of birth (MM/DD/YYYY) * (Optional)
Input - Month number
Label
Please enter a valid month.
Input - Day number
Label
Please enter a valid day.
Input - Year number
Label
Please enter a valid year.
Input - Sex
Sex (as listed on health insurance) * (Optional)  
Please select a valid sex.

Address & Contact Information

Input - Street address
Label
Please enter a valid street address.
Input - City
Label
Please enter a valid city.
Input - State
Label
Please enter a valid state.
Input - Zip code
Label
Please enter a valid zip code.
Input - Email
Label
Please enter a valid email address.
Input - Phone number
Label
Please enter a valid phone number.
Input - Phone type
Label
Please select a valid phone type.
Input - Preferred contact method
Preferred contact method * (Optional)
Please select a valid contact method.

Patient Visit Information

Reason for visit label
Reason for visit:
Input - Visit details
Label
200/200 Please enter valid additional details.

Insurance Information

Upload insurance card images * (Optional)
Input - Insurance card front image
Label
Placeholder
Front of insurance card
Input - Insurance card back image
Label
Placeholder
Back of insurance card
Please upload an image of the front and back of your insurance card.
Input - Insurance provider
Label
Please select a valid insurance provider.
Input - Insurance member ID
Label
Please enter a valid member ID.
Input - Insurance group number
Label
Please enter a valid group number.
Disclaimer - Insurance
If you choose not to upload or add insurance information, please bring a copy of your insurance card with you to the appointment.
Input - Submit
Some required fields have not been filled in. Please review each section carefully & fill in all required fields to continue.