Telemedicine Request

Please enter your details below to be contacted by a medical doctor to discuss your medical history and condition. This information is sent directly to the medical office. Someone will contact you to set up an appointment within 72 hours.

Parent/Contact name *

First

Middle

Last

Parent/Contact Email *

Address *

City *

State

Pennsylvania

ZIP *

Phone Number *

Best Time to call you *

We will do our best to call you during the time you prefer. Please note that due to a high volume of requests, we cannot guarantee the selected time.

Patient name *

First

Middle

Last

Patient gender *

Female
Male

Patient Date of Birth *

Confirmation *

I confirm the information above is correct and I am contacting a physician to inquire to become an established patient.

This form is not a binding agreement and a physician will contact you to discuss fees and payment options. This service is not covered by insurance and you will be responsible for full payment for services rendered.

FAQ

Are medical exemptions legal in Pennsylvania?

Medical exemptions are allowed in Pennsylvania for both masks and vaccinations.

Vaccine exemption (K-12)

Vaccine exemption (Child Care)

Mask exemption