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Available Forms

1. Patient Demographics

Please call 202-368-6820 prior to submitting forms so we can make sure you are in our coverage area. All questions contained in this questionnaire are strictly confidential and will become part of your medical record. A typical phone, text or video consultation starts at $60.00. If after this consultation a house call visit is needed, we will credit your consultation fee to the house call visit. If the patient has a Primary Caretaker, please be considerate of the patient and doctors time. Only the primary caretaker or 1 designated person should be in the room with the patient and doctor.

Patient Information

At least one phone number is required.
Required for Portal communications
Check all that apply
Name, Address and Phone
Name, Address and Phone
Name, Address and Phone Number
Please make sure all information is exactly as information on Credit Card as the visit will be charged to your card prior to doctors arrival. We do not accept Debit Cards for prepayment.
If different from patient.
If different from patient.
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