What is your relationship to the patient? *

I am the Patient

I am the Legal Representative

I am Senior Living Community Representative

I am a Family Member/Caregiver

Can the patient make their own decisions or is there a Power Of Attorney? *

Power of Attorney

Makes Own Decisions

Can't Make Own Decisions and Has no Legal Representative

Patient Legal Name *

First Name

Last Name

Patient Date of Birth *

MM

DD

YYYY

Patient Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Services/Documents Requested

Doctor Visit

602A

POLST

Admission orders

Medication Reconciliation

TB Clearance (Mobile X-ray: results are 24-48 hrs)

TB Clearance (QuantiFERON: results are 3-5 days))

COVID-19 (PCR or home test)

Other

I agree to Doctor2me's Terms of Service, Arbitration Agreement, Consent to Treat, Privacy Policy, Cancellation Policy located at https://www.doctor2me.com/terms *

Yes