Schedule a TeleMedicine Video Call Due to recent unfortunate situations in our society with the COVID-19 pandemic, we are offering easier access to our patients with at home Doctor Visit accessibility. For more information on the State of Arizona Executive Order and Expansion of TeleMedicine, please click here. In-Network with BCBS, UHC & AETNA. Cash Pay patients are not required to upload your insurance card or Driver's License. COVID-19 Coronavirus Testing results are provided 24 to 48 hours. Lab testing is provided by MicroGen, which is FDA Approved. Please fill out the following information prior to your scheduled e-Visit TeleMedicine Video Call. First Name (required) Last Name (required) Your Email (required) Phone Address Apt/Suite City State Zipcode Upload Copy of Driver’s License Upload Insurance Card Front Upload Insurance Card Back Past Medical History Chronic Family Conditions Medications, Vitamins and Supplements Medication or Food Allergies Past Surgical Procedures / Injuries / Hospitalizations Are you a smoker? YesNo Do you drink alcohol? YesNo Alcohol use Notice of Privacy Practices Reason for e-Visit? Pharmacy Name Pharmacy Phone Number Pharmacy Address Patient’s TeleMedicine Video e-Visit will be scheduled with the convenience of using FaceTime, Skype or WhatsApp. Co-PayCash (Not required to upload DL or Insurance Card) Select Co-Pay Amount 1015202530354550 Select Amount 195 Select Amount 200 COVID-19 Test $200 Total Name on Card Card Number CVV Card Expiry (mmyy) I agree to theseTerms and Conditions Δ
