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tele/video consultation request

THIS EXPERIMENTAL SERVICE IS PROVIDED AS AN ALTERNATIVE TO A CUSTOMARY OFFICE VISIT FOR THOSE PATIENTS WHO ARE OUT OF THE AREA OR UNABLE TO BE SEEN IN AN OFFICE VISIT. IF POSSIBLE, AN IN PERSON OFFICE VISIT IS RECOMMENDED AND ALWAYS PREFERRED.

TO ARRANGE A CONSULTATION, YOU MAY CONTACT THE OFFICE DURING OFFICE HOURS IN THE USUAL MANNER BY PHONE, EMAIL OR UPDOX MESSAGE. AFTER HOURS, OR IF YOU WISH, YOU MAY COMPLETE THE FOLLOWING FORM TO REQUEST A CONSULTATION.

YOUR REQUEST WILL BE ADDED TO OUR INCOMING MESSAGES, AND ATTENDED TO IN THE ORDER RECEIVED BASED ON TRIAGE PRINCIPLES. SCHEDULED APPOINTMENTS WILL ALWAYS TAKE PRIORITY, AND THERE IS NO GUARANTEE OF A CONSULTATION BASED ON THE REQUEST. YOU CAN ALSO CALL DURING OUR USUAL OFFICE HOURS TO SCHEDULE A TIME.

 
your name here.
complete if not logged in securely.

Your consultation will require a device with video and audio capability (phone, computer or tablet). When prompted, authorize Updox to enable video and audio.

phone number or e-mail for the device you wish to use for your consultation.
 
Briefly describe the ONE topic you wish to be consulted about.

THERE MAY BE A CHARGE ASSOCIATED WITH THIS CONSULTATION, AT THE DISCRETION OF DR. ZWAAN. IF POSSIBLE, WE WILL TRY TO BILL YOUR INSURANCE, BUT USUAL DEDUCTIBLES AND COPAYS MAY STILL APPLY AND WE CANNOT GUARANTEE THAT THE COST WILL BE COVERED. ACCORDINGLY, WE RESERVE THE OPTION TO CHARGE YOU A MINIMUM/BASE CHARGE OF $40 TO OFFSET OUR EXPENSES. FOR EXTENDED VISITS, A CHARGE OF $50 / 15 MINUTES MAY APPLY.

 
if a medication is prescribed, and you have a preferred pharmacy near your location, you may want to list it here.
 

Consultations may be scheduled, or may occur when I am not scheduled to see patients: Before 9am, 12:30pm - 1:30pm, after 5pm, Thursdays, Weekends, Holidays, all at the discretion of Dr. Zwaan. They may occur during work days if confirmed, between seeing other patients as the schedule allows, or as the situation warrants.

If you wish, list the times you are definitely available or definitely not available.

Thank you for your consultation request.

Keep an eye out for a text or e-mail invitation with a link to start your video conference.

IF YOUR PROBLEM IS URGENT, AND YOU DO NOT HEAR FROM US, CALL US OR SEEK CARE AT A NEARBY FACILITY.

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