Jump to Content
SANJEEV PRAKASH, MD
Home
Forms
Available Forms
Credit Card Payment
Existing Patient Information Update
Existing Patient Request for Appointment
Message Form
NEW PATIENT APPOINTMENT Request Form
New Patient Information
Telemedicine Visit Request
Telemedicine Visit Request
Last name
*
First name
*
Date of Birth
*
Have you seen Dr. Prakash at least twice in office?
*
Yes
No
Which one of these devices do you have?
*
-- Please Select --
Computer with Internet, webcam & microphone
iPhone
iPad
Android phone
Android tablet
Will you be able to do blood tests if your medication requires periodic monitoring?
*
Yes
No
Do you have an updated list of medications?
*
Yes
No
Which insurance do you have?
*
Medicaid
Medicare
Other
How do you plan to pay for co-pay/deductible?
*
Credit Card
Check
Any other information that you think the doctor should know?
* Required field
Submit Form