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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 PainChest PainCoughDiarrheaFeverHeadacheShortness of breathVomiting

    What Are Your Symptoms? *

    Security Code: *
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    Cost of Visit: $50.00 . After submitting the form, you’ll be redirected to pay online.