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Before proceeding with a request for consultation, please check doctor's availability by entering your ZIP code, desired appointment time and doctor's type. For blood work, please select Phlebotomist as doctor's type.

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Patient Information
First Name Last Name
Street Apt or Room
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State ZIP
Phone
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Age Location Type
Email
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Is patient and billing address is the same?
Payment Information
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Credit Card Card Number
Expiration Month Year CVV Number (what is it?)
Name On Card
Street Apt #
City
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Patient Questionnarie
Describe your chief complaint:
Is this related to trauma or accident?
Are you pregnant, trying to get pregnant, or breast feeding?
Are you currently taking any medications?
Do you have allergies to any medictations, food or otherwise?
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?
Do you have a family member or authorized representative with whom MDPoint or affiliate physician can leave a message?
Have you ever been arrested for drug (legal or illegal) related activities?
Acknowledgement
I understand that I will be financially responsible for payment for consultation directly to the health care provider. The payment is expect at the time of consulation. In addition, I agree to accept management charges in the amount of $9.95 from MDPoint.com after consultation will be concluded.
I agree that information collected on this website will be released to health care provider for the purpose of scheduling appointment.
I have Read, Understand and Agree with MDPoint Privacy Practices Notice and Terms of Use.

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.

 

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