SCHEDULE A VIRTUAL CARE APPOINTMENT

SCHEDULE A VIRTUAL CARE APPOINTMENT

Please Fill Out The Following Information

Patient's First Name

Patient's Last Name

Are you filling this out on behalf of the patient?

First Name of Person Filling Out This Form

Last Name of Person Filling Out This Form

Phone

Have you been in contact with a person DermRight has diagnosed or is treating for scabies?

Yes

Note:

Date of Bith

Enter Address

Unit # (If applicable)

Current Weight (if under 18yo)

Please provide as much detailed information as possible.

Pharmacy

Upload a clear Up Close image of the problem area.

Upload Image #1

Upload a clear image of the whole area.

Upload Image #2

Upload a face/headshot picture of the patient.

Upload Image #3

Front of Insurance Card(s)

Upload Image #4

Back of Insurance Card(s)

Upload Image #5

I acknowledge that this virtual visit is treated the same as an in office visit and will be submitted to my insurance for reimbursement. Any regularly applicable copays, coinsurance, or deductible would apply. I also consent to uploading Protected Health Information, including photos which are required for the medical purpose of assessing, diagnosing, and treating dermatological conditions.

Your Signature