Telemedicine -

Please complete the form below. Make a payment for

Medical Consultation for 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

Note: Currently, we are accepting patients in PA state only for Telemedicine. We will be adding the other states soon.

Once our staff receives your completed form and the payment, you will receive a text for the time of your appointment.

At the specified time, the doctor will initiate the 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

Social Security # *

Patient SS # format xxx-xx-xxxx

Driver License # and State of License *

If none, enter N/A

Cell Phone # *

format 555-555-5555

Home Phone #

Format 555-555-5555

Email *

if None, enter N/A

Patient Home Address *

City, State, Zip Code *

Name, City and State of Pharmacy *

for patient

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.

Telemedicine

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