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Request a Virtual Consultation

Virtual Consultation Form


History & Physical


Medical History


Surgical History




Current Medications


Detailed Health Questionairre

  • Cardiovascular

  • Respiratory

  • Digestive

  • Urinary

  • Endocrine

  • Neuro

  • Sensory

  • Muskuloskeletal

  • Psychiatric

  • Cancer

  • Female Reproductive

  • Infectious disease

  • To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment.

    1. Use a solid background.
    2. Take one frontal photo with the face or body centered and looking straight.
    3. Take at least one, preferably two profile photos
    4. Must upload a Photo ID for our records.

    File formats accepted: gif | png | jpg | jpeg
    File size limit: 3mb'
  • Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree

    *Alert: All Fields Must Be Complete for eligibility - A $50.00 Virtual Consultation Fee will be required prior to submission