Telehealth Service Request
Please email a copy of your photo ID & insurance cards (front & back) to office@yalepodiatrygroup.com.
Patient Name *
Your answer
Date of Birth *
Your answer
Contact Number *
Your answer
Address *
Your answer
Legal Representative\Responsible Party (Parent\Guardian\POA) *
Your answer
Legal Representative\Responsible Party Contact Number *
Your answer
Legal Representative\Responsible Party Address *
Your answer
Have you been treated in our office before? *
When are you available for a tele-medicine appointment ?
What type of foot problem are you currently experiencing? For how long? *
Your answer
Do you have any Allergies to Medications ? *
Your answer
What is your preferred pharmacy? Please specify the pharmacies address. *
Your answer
Primary Care Physician
Your answer
Primary Care Physician Contact Number
Your answer
Our podiatrist may need to request the following records for evaluation, required for the continuation of your care. Please check off the following medical records you wish to authorize to have released from your primary care physician to Ansonia Podiatry Associates, LLC. *
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