SUBSEQUENT ONLINE CONSULTATIONS
(Second and Follow Up Visits)
Subsequent Online Consultations ($50.00)
Payment Options: VISA, Mastercard, AMEX, Discover
 
MEDICAL INTAKE FORM
Name:
Home Address:
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How are you?
What can we do for you on this Visit?
 
I acknowledge that the above information is true and accurate, and I give consent to online consultation with Dr. Conyette. I agree that Dr. Conyette may refer me to the appropriate specialists and therapists if the need arises. I agree that Dr. Conyette may need to contact me by phoning me collect in order to clarify pertinent information. Results and recommendations may take up to two weeks.

By typing your initials here, you are verifying your agreement to the above statements:


Email: paulconyette@hotmail.com