CHENNELL FAMILY WELLNESS
Telehealth Appointment Request Form
How did you hear about us?
From a friend
Insurance (Company, ID and group number)
Brief Description of Symptoms:
Preferred Appointment Time
I agree that appointments are at the sole discretion of the doctor. I agree that my insurance information provided is accurate. I agree that my insurance will be charged for the services provided unless I request cash pay. I agree to provide credit card information for any services my insurance does not cover. I agree this does not constitute a patient-provider relationship with the doctor and will be a one-time visit unless mutually agreed upon otherwise. I understand it may take up to 24 hours for a response to my request.
Thanks for submitting!