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).
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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
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Please Upload any medical files and proof of medical diagnosis here
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What are your allergies?
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What are your allergies
What medications do you take?
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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 (examples include: Adderall (amphetamine/dextroamphetamine), Vyvanse (lisdexamphetamine), or Ritalin (methylphenidate)), anxiety medicines (Xanax (Alprazolam), Valium (diazepam), Ativan (Lorazepam), or Klonopin (Clonazepam)), sleep aids (like Ambien (zolpidem), Lunesta (eszopiclone), or Sonata (zaleplon)), Neurontin (gabapentin), or pain medicines (like Percocet (Oxycodone-acetaminophen), Norco (hydrocodone-acetaminophen), or other opioid).
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No, I am not on any controlled medications
Yes, I currently take or have had a prescription for a controlled medication. IMPORTANT NOTICE: If you select this box, YOU MUST CONTACT OUR OFFICE BEFORE SUBMITTING THIS FORM. FAILURE TO DO SO MAY RESULT IN YOUR REQUEST BEING DECLINED. Certain controlled medications may affect medical eligibility, require documentation or coordination with the prescribing clinician, or result in delay or denial of certification, based on clinical judgment and applicable Virginia law and regulations. Submission of payment does not guarantee certification or approval
Are you taking, or have you ever taken (in the past 3 years), Suboxone, Methadone, Buprenorphine, or any other medicine used to treat opioid addiction?
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No, I am not on any of these
Yes, I currently take or have taken one or more of these medications. IF YOU SELECT THIS OPTION: STOP. DO NOT CONTINUE. CONTACT OUR OFFICE BEFORE COMPLETING THIS FORM. Failure to do so will result in your consultation request being declined
Please share your past experiences, current knowledge level, and whether you’re new to this or doing a renewal. 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.
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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
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We must have this information to see you beginning December 1, 2025
Take Photo of Your Virginia Drivers License or Virginia State ID To Upload Here (Must be uploaded for us to meet with you)
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Signature
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Telemedicine Visit
Payment is for a professional telemedicine medical evaluation and associated administrative services only. Payment does not guarantee the issuance of a medical certification or any particular clinical outcome. All patients are evaluated individually based on medical history, clinical findings, and professional judgment, in accordance with applicable laws and standards of care.
$
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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