VIOS Clinic Patient Registration Form
We’d like to welcome you as a new patient! Please take the time to fill out this form as accurately as possible so we can give you the best service. 
The confidentiality of your health information is protected in accordance with federal protections for the privacy of health information under the Health Insurance Portability and Accountability Act (HIPAA). This form is encrypted and secured by Google for the collection and storage of ePHI (electronic personal health information). You will be entered into our weekly newsletter mailing list, you may unsubscribe at any time.

Email *
Email (please insert your personal email) *

Are you creating this profile on behalf of someone else? eg. your child, spouse, parent

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Please ensure that you are able to provide valid information to complete this form.

Please confirm that you are seeking consults for a non-emergency case

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We are unable to provide emergency or urgent care through our platform.

Is the patient currently in the United States?

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Which state is the patient residing in? (For international patients, please mention the city & country)

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What is their Zip Code (or P.O.Box?)

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What is the patient's name?

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Is the patient 18yrs or older? (An adult guardian must be present in the Zoom call for consults with minors)

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As per COPPA regulations, only applicants 18yrs or older may complete our intake forms, unless supervised by an adult.

What is their age?

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What is the mobile number to which we may send an SMS (for scheduling confirmation or meeting links). 

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For International Patients, please mention the country code.

What is the email to which we may send communication-related information to?

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What were the initial complaints discussed with the previous doctor, and for how long did they experience them?

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Did the previous Doctor perform a physical examination* before making their diagnosis?

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*A physical examination is when a physician uses their hands, a stethoscope or any other medical tool to examine your body to asses your chief complaints, or for a general overview of your health.

What was the Diagnosis?

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If you have the relevant medical reports, please upload them here. You may skip this section if you wish

Please mention the medications currently prescribed.

Were any diagnostic tests performed? eg. Xrays, MRIs, Ultrasound

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Please list surgeries and/or hospitalization reasons and dates.

Is the patient sufferring from any of the following diseases? If so, please provide some more details at the end of the questionnaire.

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Is there a Family History of any of the following diseases? 

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Which specialty were you looking for?

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If unsure, we will assess your intake form & connect you with the appropriate specialty

Please select the key services required. This will help your provider to personlaize their virtual visit for you.

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Required

Is there any other relevant medical or health-related information you would like to tell the Doctor?

When would you prefer to have your telemedicine visits? Select all that may apply.

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Required
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