Tele-Med Examination Appointment Request

Name: Bison Vision Center
Address: 585 Murphy Rd., Medford, OR, 97504, US
Telephone: (541) 773-1414
Price range: $000 - $300

Please fill in the form below to request a Tele-Med Examination Appointment.
Name*
First Last
Phone*
Email*
Patient Type*
- New patient
- Returning patient
Has Occupational Therapy, Physical Therapy, Speech and Language Therapy been assigned?*
- Yes
- No
Name of Therapist
First Last
Facility
Phone
Email
Name of Therapist
First Last
Facility
Phone
Email
Name of Therapist
First Last
Facility
Phone
Email
Preferred Dates & Time*
Preparations For Appointment
- Download SKYPE to Your Cell Phone
- Provide Your Phone Number to bvc@hipaasecurity.us
Once I have this information, I will call to schedule our tele-med appointment.
Efforts to be in full compliance with constantly emerging federal, state, and Oregon Board of Optometry requirements to provide these TELE-MED services may cause delay contacting the patient .
I have developed a network of OT's who are hospital affiliated or in private practice to provide the follow-up therapy visits making In-patient, Outpatient, and Home Therapy options available.
I will do my best to guide you through this new and intimidating territory to be the best you can be.
Comments
Name
This field is for validation purposes and should be left unchanged.

Preparations For Appointment