StaffCare Form | MediTelecare

Do not request emergency appointments through this form. Please go to the emergency room or call 911 if you have an emergency.
- First Name*
- Last Name*
- Email Address*
- Phone Number*
Please continue the form by filling out the fields below:
- Gender*
- Date of Birth*
  MM
  DD
  YYYY
- Address*
  Street Address City State ZIP Code
- Health Insurance Company / Plan*
- Health Insurance ID Number*
- Health Insurance Group Number*
- Credit card information for copay/self pay.
  This information is collected for copays/self-pay only and would be charged only when a visit/session is done. Nothing will be charged ahead of time.
- Credit card number*
- Credit card number*
- Expiration Date*
  MM slash DD slash YYYY
- 3-digit CVV number on back of card*
- 4-digit CVV number on front of card*
- Pharmacy preference
- Pharmacy phone number
- Pharmacy address
  Street Address City State ZIP Code

Please make selections below for your preferred appointment times. The first choice date and time is required.
- First Choice Date*
  MM slash DD slash YYYY
- First Choice Time*
  
  : HH
  
  MM
  
  AM/PM
- Second Choice Date
  MM slash DD slash YYYY
- Second Choice Time
  
  : HH
  
  MM
  
  AM/PM
- Third Choice Date
  MM slash DD slash YYYY
- Third Choice Time
  
  : HH
  
  MM
  
  AM/PM
What is your preferred way that we should contact you?*
- Email
- Phone call
- Text message
Can we leave a voice message at the phone number you’ve provided?*
Please confirm your mobile number for text messages.*

Medication	Doseage	Times per day