MDPoint - House Call Doctors

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Your ZIP Code

Appointment Time

Doctor's Type

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Patient Information
First Name		Last Name
Street		Apt or Room
City
State		ZIP
Phone		Gender
Age		Location Type
Email		Verify Email
Is patient and billing address is the same? Yes No
Payment Information
Select Payment method	Credit cardCheck

Credit Card		Card Number
Expiration	Month Year	CVV Number	(what is it?)
Name On Card
Street		Apt #
City
State		Zip

Patient Qustionnarie
Describe your chief complaint:

Is this related to trauma or accident?	Yes No	If "Yes", please explain here.

Are you pregnant, trying to get pregnant, or breast feeding?	Yes No	If "Yes", please explain here.

Are you currently taking any medications?	Yes No	If "Yes", please explain here.

Do you have allergies to any medictations, food or otherwise?	Yes No	If "Yes", please explain here.

Does MDPoint or affiliate physician have your permission to leave a message related to your care on your cell phone and or your home phone?	Yes No	If "Yes", please explain here.

Do you have a family member or authorized representative with whom MDPoint or affiliate physician can leave a message?	Yes No	If "Yes", please explain here.

Have you ever been arrested for drug (legal or illegal) related activities?	Yes No	If "Yes", please explain here.

Acknowledgement
I understand that I will be financially responsible for payment for services and I agree that my credit card will be charged prior to the appointment with health care provider.	Yes No
I agree that information collected on this website will be released to health care provider for the purpose of scheduling appointment.	Yes No
I Have Read, Understand and Agree with MDPoint Privacy Practices Notice.	Yes No

Important ! If you are experiencing chest pain, bleeding, shortness of breath, confusion, dizziness, major pain, serious trauma or burns, and other life threatening emergencies, please don't wait and call 911 immediately.

Now serving the following areas: San Francisco, CA / Los Angeles, CA / Phoenix, AZ / Raleigh-Durham-Chapel Hill, NC / Miami, FL.

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