Telemedicine You have selected the PayPal checkout Account Information Username Password E-mail Address First Name Last Name Date of Birth JanFebMarAprMayJunJulAugSepOctNovDec Address Present Phone Number : Phone Number 1 Phone Number 2 Past Medical History : 1. 2. 3. 4. 5. 6. 7. 8. Any Past Surgery : 1. 2. Any alergy to any medicine : 1. Present Doctor’s Name & Phone Number : Present Doctor’s Name Present Doctor’s Phone Number Medicine presently taking and dose : 1. 2. 3. 4. 5. 6. Agreement I agree with the limitation of the telemedicine practice. I agree to consult a local doctor if needed. Full Name LEAVE THIS BLANK Processing...
