Online Patient form for Pediatric Telemedicine
Please fill in the details and accept the conditions. You will recieve another email with next steps. Feel free to email us back at help@pediatricshealthcareassociates.com or call us at 602-456-6414 for any additional questions.
Email *
What is your full name? (First Name, Last Name) *
Your phone number *
Your address? (Please include street address, city, state and zip code) *
Your relationship to the patient (child)? *
Patients (Child's) name? (First Name, Last Name) *
Patients Date of Birth *
MM
/
DD
/
YYYY
Patients Gender *
Please tell us briefly the reason for visit today? *
By entering you name below, You acknowledge and attest that you have received and read the consent for Telehealth services and treatment (Please click on this link to read more http://www.pediatricshealthcareassociates.com/telehealth-consent-form ): Enter your name again *
By entering your name in the box below, you consent to "Telemedicine HIPAA Notice for privacy": (Please click on this link to learn more https://www.pediatricshealthcareassociates.com/hipaa-notice) Please enter your name in this box *
Which State are you from? *
Which state are you setting up this appointment from? (State you will be physically present during appoinment) *
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