Telemedicine - Bizgrouplink Blog

Please complete the form below. Make a payment for:

Medical Consultation (up to 15 mins): $60.00
Detailed Medical Consultation (up to 30 mins): $120.00
Weight Loss consultation: $85.00
Suboxone Opioid Treatment: $100.00

Once we receive your completed form and payment, you will receive a text with your appointment time.

At the time of the appointment, the doctor will initiate telemedicine.

Patient Registration Form and Payment

Purpose of Telemedicine *

Describe your request for telemedicine

Name *

First

Last

Multiple Choice *

Male
Female

Patient D.O.B. *

D.O.B format mm/dd/year

Driver License # and State of License *

If none, enter N/A

Cell Phone

Patient cell #

Email *

if None, enter N/A

Patient's Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Name, Address, City and State of Pharmacy *

Patient's Pharmacy Information

By signing below, I authorize the use of my health information for medical consultation. I authorize direct payment to my physician. I permit a copy of this authorization to be used in place of the original. *

write your name

If patient is less than 18 years of age, Name of Parent *

if patient is 18 years old or older, write N/A

Credit Card Details *

Amount to be Paid for consultation *

select one

Thank you.