CARY ADULT MEDICINE - Publicforms

Available Forms

Back Pain E-Visit Billing Question Blood Pressure Log Blood Sugar Readings Cold/Flu/Sinus/Cough//Throat/Respiratory Infection Comments or Suggestions Conjunctivitis/Pink Eye Depression Screening (PHQ9) Flu Shot Health Care Question HIPPA Hospitalization Insurance Change Form Lab Result Follow-up Question Living Will/Health Power of Attorney Medical History/Preventative Update Medicare Wellness Exam New Patient Medical History New Patient Registration Form Password - Patient Request for Secure Password Patient Education Classes Prescription Refill Request Preventative Care Referral Question Specialist/ER/Hospital/Testing Update Specialist/Urgent Care or Hospital Visits Survey- Cary Adult Medicine Telemed Urinary Tract Infection Voluntary Alignment for Medicare ACO REACH Yeast Infection

Telemed

If you would like to request a telemed visit, please complete this form. If we are able to treat your condition or questions through telemed , you will receive a confirmatory email or call.

First Name *

Last Name *

Date of Birth *

Type of Insurance *

Reason for Telemed *

Requested TIME *

8-9 am

9-10 am

10-11 am

1-2 pm

2-3 pm

3-3:30 pm

Other

Pick all times that work

Cell Phone

Please provide a cell phone number. If you dont have a cell phone or wish to do from your home phone and computer go to next box and type in email. You will receive the link to your cell or email. You will be able to do the visit from your phone or home computer or laptop

Please provide an email to receive the link. Even if using a cell phone please provide an email as a backup.

* Required field