****************Telemedicine Consent Form****************
1
Patient Information
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2
Consent for Telemedicine Services
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3
Gwinnett Clinic Financial Policy
Name
Name
*
First
Last
Date of Birth
Date of Birth
/
MM
/
DD
YYYY
Email
*
Phone
Phone
*
-
###
-
###
####
When would you like your appointment? (Check all that apply)
*
When would you like your appointment? (Check all that apply)
First Available
Within the Week
Next week
This Month
Monday
Tuesday
Wednesday
Thursday
Friday
I already have an appointment
Drivers License/Identification Card
Attach Files
What’s the reason for your request?
*
Primary Care: Wellness/Physical Visit
Primary Care: Sick Visit
Primary Care: Refills
Primary Care: Other
Specialty Care: Allergy and Asthma
Specialty Care: Cardiology
Specialty Care: Neurology
Specialty Care: Orthopedic
Specialty Care: Physical Therapy
Provider Name
Dr. Antonios Pothoulakis (Cardiology)
Dr. Asha Shah (Primary Care)
Dr. Byol Shin (Allergy, Asthma & Immunology)
Dr. Daniela Tanase (Primary Care)
Dr. Deep Shah (Primary Care)
Dr. Dinesh Raju (Neurology and Sleep Medicine)
Dr. Gabriel Nguena (Primary Care)
Dr. Hong Wang (Primary Care)
Dr. JJ Shah (Orthopedic Surgery)
Dr. Joo Won Lee (Primary Care)
Dr. M. Kumareswaran (Primary Care)
Dr. Meena Shah (Primary Care)
Dr. Ned Armstrong (Orthopedic Surgery)
Dr. Padmini Gunadeva (Primary Care)
Dr. Rachel Shah (Primary Care)
Dr. Raja Ram (Primary Care)
Dr. Richard Goodjoin (Primary Care)
Dr. Savita Joshi (Primary Care)
Dr. Shveta Raju (Primary Care)
Ms. Angela, FNP-BC (Primary Care)
Ms. Jessica, FNP-C (Primary Care)
Ms. Kayla, FNP-BC (Primary Care)
Ms. Lora, FNP-BC (Neurology)
Ms. Michelle, FNP-C (Primary Care)
Ms. Page, AGPCNP-BC (Primary Care)
Mr. Nishith Oza (Physical Therapy)
Location
*
Auburn Clinic
Braselton Clinic
Dacula Clinic
Duluth/Breckinridge Clinic
Duluth/Pleasant Hill Clinic
Jefferson Clinic
Lawrenceville (Main) Clinic
Johns Creek Clinic
Lilburn Clinic
Loganville Clinic
Monroe Clinic
Patterson Clinic
Peachtree Corners Clinic
Snellville Clinic
Sugar Hill/Buford Clinic
Suwanee Clinic
Tucker Clinic
Webb Gin Clinic
Winder Clinic
Specialty: Allergy and Asthma
Specialty: Cardiology
Specialty: Neurology
Specialty: Orthopedic
Specialty: Physical Therapy
No Preference
Have you visited any of our offices before?
*
Yes, I am an established patient.
No, I am a new patient
Primary Insurace Company
Ex; Private Pay (No insurance), BCBS Anthem, Aetna, Humana, Medicare, Medicaid, Etc.
Insurance Member ID Number
Please upload a photo of the FRONT of your Insurance Card
Attach Files
Please upload a photo of the BACK of your Insurance Card
Attach Files
FOR MEDICARE PATIENTS ONLY, I would like to participate in monthly health and prevention check-ins with my doctor (Chronic Care Management).
Yes, I would like to participate.
No, I would not like to participate.
I would like more information.
Would you like contact-free delivery of your medications at no additional charge (a courtesy for our patients)?
Yes
No
I would like more information.
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