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Online Patient form for Pediatric Telemedicine
Please fill in the details and accept the conditions. You will recieve another email with next steps. Feel free to email us back at
help@pediatricshealthcareassociates.com
or call us at 602-456-6414 for any additional questions.
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* Indicates required question
Email
*
Your email
What is your full name? (First Name, Last Name)
*
Your answer
Your phone number
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Your answer
Your address? (Please include street address, city, state and zip code)
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Your answer
Your relationship to the patient (child)?
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Your answer
Patients (Child's) name? (First Name, Last Name)
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Your answer
Patients Date of Birth
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MM
/
DD
/
YYYY
Patients Gender
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Female
Male
Other:
Please tell us briefly the reason for visit today?
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Your answer
By entering you name below, You acknowledge and attest that you have received and read the consent for Telehealth services and treatment (Please click on this link to read more
http://www.pediatricshealthcareassociates.com/telehealth-consent-form
): Enter your name again
*
Your answer
By entering your name in the box below, you consent to "Telemedicine HIPAA Notice for privacy": (Please click on this link to learn more
https://www.pediatricshealthcareassociates.com/hipaa-notice
) Please enter your name in this box
*
Your answer
Which State are you from?
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Arizona
Pennsylvania
Wisconsin
Other:
Which state are you setting up this appointment from? (State you will be physically present during appoinment)
*
Your answer
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