[AdvancedMD] Provider (CODE)
Patient Name
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First Name
Middle Name
Last Name
Phone Number
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Patient Email
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example@example.com
Patient Date of Birth
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Month
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Day
Year
Date
Sex Assigned at Birth
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Male
Female
Patient Service Address
*
Street Address
Street Address Line 2
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Preferred Doctor Appointment
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Contact Name
First Name
Middle Name
Last Name
Contact Phone Number
Contact Email
example@example.com
Service Requested
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( X )
Home Visit
$
1.00
Televisit
MD Televisit
$
175.00
Home Visit with 15 mins travel
$
450.00
Home Visit with 30 min travel
from zip codes 85255, 85262, and 85266
$
600.00
Home Visit with 45 min travel
$
750.00
Credit Card Details
First Name
Last Name
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Card Expiration
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