Telehealth Service Request

Name*
First Last
Date of Birth*
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Legal Representative\Responsible Party (Parent\Guardian\POA)*
- Self
Legal Representative\Responsible Party Contact Number*
- Self
If Other; Legal Representative\Responsible Party Address
Street Address Address Line 2 City State ZIP Code
Have you been treated in our office before?*
- Yes
- No
When are you available for a tele-medicine appointment?*
- Select All
- Morning
- Afternoon
- Evening
What type of foot problem are you currently experiencing? For how long?*
Do you have any allergies to medications?*
- Yes
- No
- Not Sure
What is your preferred pharmacy? Please specify the pharmacies address.*
Primary Care Physician
First Last
Primary Care Physician Contact Number
Our podiatrist may need to request the following records for evaluation, required for the continuation of your care. Please check off the following medical records you wish to authorize to have release from your primary care physician to Ansonia Podiatry Associates, LLC.*
- Recent Medication List
- Recent Lab Work
- Vaccination Record
- Last Encounter Chart Notes
- I do not have a primary care physician
- None- I do not authorize the release of my medical records from my primary care physician to Ansonia Podiatry Associates, LLC
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