Telemedicine Consultation
All information is strictly confidential & HIPAA protected.
Full Name
*
First Name
Last Name
Suffix
Birthdate
*
-
Month
-
Day
Year
Date (YOU MUST BE 21+)
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number. This is how we will call you to set up your video visit.
Current Address (ADDRESS MUST MATCH YOUR VIRGINIA ID).
*
Street Address
Street Address Line 2
City
State (MUST BE VIRGINIA)
Postal / Zip Code
What is your medical diagnosis? Please include date(s) of diagnosis
*
Please Upload any medical files and proof of medical diagnosis here
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What are your allergies?
*
What are your allergies
What medications do you take?
*
What medications do you take? Include over-the-counter medications, vitamins, and supplements
I do not take and am not currently prescribed any controlled medicines, such as stimulants (like Adderall or Ritalin), anxiety medicines (like Xanax or Clonazepam), sleep aids (like Ambien), gabapentin, or pain medicines (like Percocet).
*
No, I do not take and am not prescribed any controlled medications
Yes, I currently take or have a prescription for one or more controlled medications. IF YOU CHECK THIS BOX CALL US FIRST TO DISCUSS BEFORE SUBMITTING PAYMENT. SOME MEDICATIONS WILL DISQUALIFY YOU OR WILL DELAY YOUR CONSULTATION
Are you taking, or have you ever taken, Suboxone, Methadone, Buprenorphine, or any other medicine used to treat opioid addiction?
*
No, I have never taken these medicines and do not take them now
Yes, I am currently taking or have taken one of these medicines in the past 3 years. IF YOU CHECK THIS BOX CALL US FIRST TO DISCUSS BEFORE SUBMITTING PAYMENT BECAUSE WE WILL NEED A LETTER FROM YOUR DOCTOR FIRST
Please share your past experiences, current knowledge level, and whether you’re new to this. During your telemedicine visit, we’ll help you understand the risks and benefits.
*
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I CERTIFY THAT I AM A CURRENT RESIDENT OF VIRGINIA & HAVE AN UNEXPIRED VIRGINIA DRIVERS LICENSE.
*
YES, I am a Virginia Resident and I have an unexpired Virginia license
No, I am not a Virginia resident and/or do not have a valid Virginia ID
Virginia Drivers License or State ID Number
*
We must have this information to see you beginning December 1, 2025
Take Photo of Your Virginia Drivers License To Upload Here (Must be uploaded for us to see you)
*
Signature
*
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Telemedicine Visit
This is payment for a telemedicine consultation. By paying, you understand that services are not guaranteed. We will evaluate every patient equally and fairly.
$
80.00
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
Afterpay
After submitting the form, you will be redirected to Afterpay to complete the payment.
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