Tele-Med Examination Appointment Request

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

Email

This field is for validation purposes and should be left unchanged.

Preparations For Appointment

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