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Patient Name
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Patient Phone
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Patient Email
(Required)
Should the Telemedicine Provider suggest your visit continue in-person today, all charges for this Telemedicine visit will be credited for a same-day in-clinic visit. Patient (or Parent for Minors) Consents to the payment and to communicate and receive care using virtual and other telecommunications tools. This patient has been explained the risks, if any, related to encounter and that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems.
There are no payments due today for your telemed visit - please select "Completed" below to achnowledge.
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Insurance or Cashpay fees for Telemed Visit
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Telemedicine Visit Fee Increment
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Total Charges to be Collected
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Credit card number
Secure Credit Card Payment
(Required)
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Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date
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Year
Year
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Security Code
Cardholder Name
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