Virtual Visit Request Form
Request a Virtual Visit with a Bravia Dermatology Care Team member. The content submitted on this form is secure meeting HIPAA compliance requirements.
Email address *
New or Existing Patient? *
Patient First Name (Legal Name) *
Your answer
Patient Preferred First Name (Nick Name)
Your answer
Patient Last Name *
Your answer
Patient Date Of Birth *
MM
/
DD
/
YYYY
Patient Cell Phone *
Your answer
Preferred Appointment Date *
MM
/
DD
/
YYYY
Preferred Virtual Appointment Time *
Reason for virtual visit? (e.g. rash, acne, spot on nose)
Your answer
Who is your Primary Care Physician or Provider?
Your answer
Were you referred by another provider? If so, what is their name and specialty?
Your answer
Please type in your FULL NAME as your signature acknowledging our HIPAA policies, Financial Policy, and Office Policies. *
Your answer
Submit
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