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 patientReturning patientHas Occupational Therapy, Physical Therapy, Speech and Language Therapy been assigned?*YesNoName of Therapist First Last FacilityPhoneEmail Name of Therapist First Last FacilityPhoneEmail Name of Therapist First Last FacilityPhoneEmail Preferred Dates & Time*Preparations For Appointment Download SKYPE to Your Cell Phone Provide Your Phone Number to firstname.lastname@example.org 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.CommentsPhoneThis field is for validation purposes and should be left unchanged.