1PERSONAL INFORMATION
2VISIT INFORMATION/ HEALTH PROFILE
3PAYMENT
This will help us determine the nearest pharmacy if needed.
mm/dd/yyyy
Click or drag a file to this area to upload.
Please upload a picture of State ID please. This will help our facility process your information efficiantly.
The device needs to have a functional video camera and microphone. If you have any questions give us a call at (714)634-4884.
The date/time of your request will help us confirm your expected appointment time. If we are busy during your requested time one of our dedicated staff members will contact you to see the next best available time for you. If you have any questions give us a call (714)634-4884.Thank you for your understanding.
Name, Street Address, City, State