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Available Forms

Patient/Family Caregiver Request Virtual Care

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.

Language Options

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 abarbash@myupdox.com or fax directly to me at 888-905-3830

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