This is for patients referred by a primary care physician/provider who is part of the virtual care program (see below).
Your Contact Information
This must be a mobile phone at which I can contact you by text if needed.
Reason for Registering
Let me know the specific neurologic symptoms you are having and any questions
Authorization and Verification
By checking this box I am stating that I have been referred for virtual care specialty services by my primary care provider and that I will make a followup appointment with him/her afterwards. I am also confirming that I am fully responsible for the accuracy of any information provided.
How to Provide Additional Documents or Files
If you have any notes, documents, reports or medical images....you can email them directly to me at firstname.lastname@example.org or fax directly to me at 888-905-3830