Online Medical Treatment Request Form

For Non-Critical care needs, you may prefer to save the time and extra expense of an office visit by using this form to send us an email with the information you provide. One of our office or nursing staff will respond as soon as they become available. If we feel you need to come in, we will schedule an appointment for you in the reply. Please give us enough detail so that the appropriate person can contact you.
Note: It is not necessary to fill in everything, but we do need enough information to locate your records, and review them in the context of your current request. Also, while far less expensive than an office visit, this is a medical consultation for which you may be charged a copay. Check with your insurance company to be sure- many cover the entire cost of an online consultation since it saves them money.
Please remember that email communications are not guaranteed to be private. After receiving them, we handle them with the same attention to confidentiality we give all your medical records, but email replies may be seen by others with access to your computer, including your employer, depending on where you send it from and where you have us reply to.
Finally...if you do not receive a reply within 1 business day, please call our office instead- technology can save us time, but isn't perfect!
Thank you!

Name
E-mail(to respond) (required)
Phone (if  no email)
Your birthdate
Your account number(if available)

Do you have any medically related allergies(You must pick Yes or No!):  No Yes    Did not answer
Please list your medically related allergies if you checked "Yes" above:

Please explain your treatment request(be specific):


Please list medicines you are currently taking: