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Electronic Visit Request

Need treatment for a non-emergency illness and can’t get into the office? Consider doing a virtual visit.
This service is for established patients only. Typical response time is within 24 hours.

IF THIS IS AN EMERGENCY, CALL 911 IMMEDIATELY!

Based on your symptoms, here is a chart to help you determine the most appropriate health care setting for your situation.

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Source: “The Self Pay Patient” (book)

To schedule your E-visit now, please complete the following form.

First Name: *

Last Name: *

Date of Birth: *

Email: *

Billing Address: *

Street Address: *

Address Line 2:

City: *

State: *

Country: *

Phone

Common Health Issue:
 Abdominal Pain Chest Pain Cough Diarrhea Fever Headache Shortness of breath Vomiting

What Are Your Symptoms? *

Security Code: *
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Cost of Visit: $35.00 . After submitting the form, you’ll be redirected to pay online.

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