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Virtual Visit Request Form
Request a Virtual Visit with a Bravia Dermatology Care Team member. The content submitted on this form is secure meeting HIPAA compliance requirements.
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* Indicates required question
Email
*
Your email
New or Existing Patient?
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New Patient
Existing Patient
Patient First Name (Legal Name)
*
Your answer
Patient Preferred First Name (Nick Name)
Your answer
Patient Last Name
*
Your answer
Patient Date Of Birth
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MM
/
DD
/
YYYY
Patient Cell Phone (JUST NUMBERS, NO DASHES)
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Your answer
Preferred Appointment Date
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MM
/
DD
/
YYYY
Preferred Virtual Appointment Time
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Choose
No Preference
Morning - 830AM-1030AM
Mid Morning - 10AM-12PM
Early Afternoon - 12:30PM-2PM
Mid Afternoon - 2PM-4PM
Late Afternoon - 4PM-5:30PM
Reason for virtual visit? (e.g. rash, acne, spot on nose)
Your answer
Who is your Primary Care Physician or Provider?
Your answer
Were you referred by another provider? If so, what is their name and specialty?
Your answer
Please type in your FULL NAME as your signature acknowledging our HIPAA policies, Financial Policy, and Office Policies. To view our these policies, Click Here:
https://drive.google.com/file/d/1GvP7N2ZPbh71wU23V9lb42UEsecgV8DH/view
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Your answer
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