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Telemedicine
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Patient First Name
Patient Last Name
Cell Phone Number
Email
Patient Birth Sex
M
F
Reason for Today's Visit:
Asthma or Allergies
Cold, Cough, Flu, or COVID
Dental Pain
Medication Refill (not Controlled Substances)
Nausea, Vomiting or Diarrhea
Pink Eye / Eye infection
Sinus, Throat, or Other Infection (Adult or Child over 5 years old)
Skin Rash, Insect Bite, Minor Burn
Sore Throat
UTI
Yeast Infection, Bacterial Vaginosis
Telemedicine Patients: I have reviewed Saint Catherine’s Telemedicine Center
Yes
No
I understand that if I have a commercial Insurance, I will be asked to leave a card on file.
Yes
No
How did you hear about Saint Catherine’s Telemedicine Service?
Google
Saint Catherine’s Telemedicine Website
Print ads
E-mail Announcement
Social Media
Friends/Family
Other
Do you have a primary care physician?
Yes
No
Do you need assistance finding a primary care physician?
Yes
No
