Telemedicine Appointment Request Form
Please fill out this form to request an appointment with Somi Javaid MD & Associates / HERmd. We are now seeing patients in all 50 states.
First Name *
Last Name *
Email *
Phone *
Desired Appointment Date (we cannot guarantee appointment date, but will do our best to accommodate all patients) *
MM
/
DD
/
YYYY
Desired Appointment Time (we cannot guarantee appointment time, but will do our best to accommodate all patients) *
Time
:
Appointment Type *
Payment Type *
Provider *
Existing Patient or New Patient? *
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