College Doc-Book a Visit

PATIENT INFORMATION SHEET
Select your appointment time
Scheduling Notice

We strive to see patients as close to their selected appointment time as possible. Due to provider availability, patient volume, and medical emergencies, actual visit times may vary. If there is a significant delay, we will notify you using the contact information provided.
Name

First NameLast Name
Phone Number
(###) ###-####Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Email
example@example.com

What do you need today?
What type of note do you need?
Do you only need a note, or do you need medical evaluation/treatment?
What dates need to be covered by the note? Example: June 14–16
Briefly describe your symptoms or reason for today's visit
How would you like to pay?
Important Billing Notice

I understand that the School/Work Note Only visit is intended for documentation purposes only. If the provider determines that medical evaluation, diagnosis, treatment, prescription medication, or additional medical management is necessary, my visit may be converted to a standard telehealth medical visit with a total self-pay charge of $85.

Any additional charges will be discussed with me by the provider during the visit before being processed. I authorize WellNow Health to charge my payment method on file for approved services, up to a maximum total self-pay charge of $85.
Patient’s Insurance Details (If Applicable)
Insurance Company Name
Member/Subscriber ID
Policyholder’s Name (if different from patient)
Take Photo (Front & Back)
Take Photo (Front & Back)
Final Payment Amount

USDDescription

I authorize the release of medical information necessary to process this claim. I consent to virtual urgent care and confirm information accuracy.

I understand that by submitting this form, I am authorizing the release of my health information to College Doc for the purpose of receiving telehealth medical services. I acknowledge that this information may be used to provide documentation, such as a work or school note, and that it will be securely handled in accordance with applicable privacy laws.

I understand this consent is voluntary and can be revoked in writing at any time, except to the extent that information has already been disclosed.
HIPAA Consent
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PATIENT INFORMATION SHEET