Book a Telehealth Appointment

Request a convenient online visit for general health concerns, medication questions, prescription refills, follow-up care, and other non-emergency needs. Complete the form below so the care team has the information needed to review your request and prepare for your appointment.

Request an Appointment Learn About Telehealth

Online Appointments for Everyday Health Needs

Telehealth can make it easier to discuss symptoms, ongoing treatment, medication concerns, and follow-up needs without an unnecessary trip to the office. Depending on your condition, location, medical history, and the clinician's assessment, your visit may include treatment recommendations, prescription management, a refill review, testing recommendations, or referral for in-person care.

New Health Concerns

Discuss recent symptoms and common non-emergency concerns with a clinician who can determine the appropriate next step.

Prescription Requests

Request a clinical review for a new prescription when appropriate. Medication is never guaranteed and depends on medical suitability and applicable prescribing rules.

Prescription Refills

Ask about renewing an existing medication. Have the medication name, strength, directions, prescribing history, and pharmacy information ready.

Medication Questions

Review side effects, adherence concerns, treatment response, and other medication-related questions during your appointment.

Follow-Up Visits

Use telehealth for eligible follow-up care when an in-person examination is not required.

General Wellness

Discuss preventive care needs, screening questions, lifestyle concerns, and next-step recommendations.

Appointment and Prescription Request Form

Please provide complete and accurate information. A submitted request is not a prescription and does not confirm an appointment until the care team completes review and scheduling.

First Name *

Last Name *

Date of Birth *

State of Residence *

Phone *

Email *

Visit Type *

Preferred Appointment Time

Reason for Visit *

Symptoms and Duration

Medication or Refill Requested

Current Medications

Medication Allergies or Reactions

Preferred Pharmacy

Pharmacy Phone

Pharmacy Address

I confirm that the information I provided is accurate and understand that treatment and prescribing decisions are made only after clinical review.

Important: Telehealth is not appropriate for medical emergencies. If you have severe chest pain, difficulty breathing, signs of stroke, severe bleeding, loss of consciousness, or another emergency, call 911 or seek emergency care immediately.

What Happens After You Submit the Form?

Request Review

The care team reviews the information you submitted and identifies whether telehealth is appropriate for your concern.

Appointment Confirmation

You may be contacted to confirm scheduling details or to provide additional medical or pharmacy information.

Clinical Visit

A clinician evaluates your history, symptoms, medications, and treatment needs. Additional questions, testing, or an in-person evaluation may be required.

Treatment Plan

If treatment or a prescription is medically appropriate and permitted, the clinician can discuss next steps and send an eligible prescription to the pharmacy selected for the visit.

Appointment FAQ

Can I request a prescription through this form?

Yes. You can provide the medication you are asking about, but submitting the form does not guarantee that a prescription will be issued. Prescribing requires an appropriate clinician-patient evaluation and depends on your medical history, the medication, your location, and applicable rules.

Can I request a refill?

Yes. Include the medication name, strength, directions, how long you have been taking it, and your preferred pharmacy. The clinician may need additional information before authorizing a refill.

What if I do not know the exact medication name?

Describe what you are being treated for and any medication details you remember. The care team can clarify the information during review or at the visit.

Will every condition be treated by telehealth?

No. Some symptoms require a physical examination, laboratory testing, imaging, or urgent in-person care. The clinician will determine whether telehealth is appropriate.