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.
Please select one of the language options above
Your Physicians Information
After you register, your primary care provider will be contacted to verify the referral.. If so, you will receive an email invitation to the Updox patient portal.
Reason for Consult or Visit
Let me know the specific neurologic symptoms you are having and any questions
How we can Meet by Video if Needed
It often is easier to meet on video. I make this very simple and you will be able to join me without any complicated technology. You need to have a smartphone, tablet or computer, any will usually work fine. I will send you to a special link later if we decide to meet by secure video chat
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