Televisit Appointment Request | Chennell Family Well

Telehealth Appointment Request Form

First Name

Phone Number

Last Name

Address

Insurance (Company, ID and group number)

Brief Description of Symptoms:

Preferred Appointment Time

First available

Morning

Afternoon

Evening

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!

Chennell Family Wellness

Telehealth Appointment Request Form