Virtual Care Calls and Visits
Full name of person requesting
Phone number (please include if it's mobile, home, work, or other)
Preferred method of contact
Are you requesting a call or video chat for yourself or someone else?
If for someone else, please include their name, phone number and/or email address.
Which is most preferred?
If video chat is preferred, please indicate the service that they are most familiar with (Skype, WhatsApp, FaceTime, Google Hangouts, etc)
What is the best time of day and days of the week to call?
Please include any additional information here.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service