iHealth Telemedicine Visit 2.1

1

By proceeding with this form, you are agreeing to the iHealth Clinic Patient Agreement and Consent Form and the iHealth Clinic Privacy Policy as found on our website.* This field is required.

I understand and would like to proceed

2

I understand that there are inherent limitations and risks of using telemedicine due to the constraints of an evaluation that is not done in person. I understand that if I am late or do not attend the visit, I will only get a partial refund for the cost of the visit.* This field is required.

I AGREE and would like to proceed

3

Name* This field is required.

First Name

Last Name

4

What is your birthdate? * This field is required.

5

Email* This field is required.

example@example.com

Confirm Email

6

Phone Number* This field is required.Only used in case we have to contact you

Area Code

Phone Number

7

Are you allergic to any medications?* This field is required.

Amoxicillin/Ampicillin/Penicillin

Ibuprofen/Naproxen/NSAIDs

IV Contrast Dye

Sulfa Drugs

NO ALLERGIES to medication

Other

8

Are you taking any prescribed medications?* This field is required.

Yes

No

9

Do you have any kidney or liver problems?* This field is required.

Yes

No

10

Is your visit today for a NEW ISSUE or is it a FOLLOW-UP for something we've managed before?

New Issue

Follow-Up from previous issue

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Tell us about your new issue:

What is the problem?

How LONG has this been bothering you?

What makes the issue WORSE?

What makes the issue BETTER?

How SEVERE is the issue?

Is the issue CONSTANT or INTERMITTENT?

What OTHER SYMPTOMS go along with this issue?

Anything else you want to describe about the issue?

12

Tell us about your Follow-Up Issue:

What is the problem?

How is your Follow-Up Issue?

Any changes that you want to add?

Are you having any problems with your medication?

13

Do you have any pictures or documents that you want to share? (the information is secured)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

14

Text Visit:

Video Visit:

- done through Zoom using the Chat feature

- you can respond when free within the app

- visit is concluded at 3 hours or sooner

- done through Zoom via Video in real-time

- face-to-face visit via Video

- visits are about 15 minutes

15

Do you want a Text Visit or a Video Visit?

Text Visit

Video Visit

16

Pick the date and time of your Visit* This field is required.Available Hours: 9-5 M-Th; 9-2 Fr-Sa; Video Visits last 15 min.

17

You are all set! You should receive an email with the link to the online meeting. Please check your spam folder as well. At the scheduled date and time, please join the meeting. If there are any problems, you can call or text iHealth Clinic at 412-776-0231.

See you soon!

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My Products

My Bag

1

Telemedicine Visit
$45.00Edit
Back

Payment Methods

Credit Card

First Name

Last Name

Google Pay

After submitting the form, you will be redirected to the Google Pay to complete the payment process.

Apple Pay

After submitting the form, you will be redirected to the Apple Pay to complete the payment.