Telehealth Visit Request

Request a Telehealth Visit

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<form-template><fields><field required="true" type="text" name="first-name" placeholder="First Name*" label="First Name"/><field required="true" type="text" name="last-name" placeholder="Last Name*" label="Last Name"/><field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/><field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/><field required="true" type="select" name="select-location" label="Select Location"><option selected="true" value="">Select Location*</option><option value="Altamonte Springs">Altamonte Springs</option><option value="Apopka">Apopka</option><option value="Celebration">Celebration</option><option value="Clermont">Clermont</option><option value="Davenport">Davenport</option><option value="Dr. Phillips">Dr. Phillips</option><option value="East Orlando">East Orlando</option><option value="Hunters Creek">Hunters Creek</option><option value="Kissimmee">Kissimmee</option><option value="Lake Worth">Lake Worth</option><option value="Mount Dora">Mount Dora</option><option value="Ocoee">Ocoee</option><option value="Poinciana">Poinciana</option><option value="Sanford">Sanford</option><option value="St. Cloud">St. Cloud</option><option value="Sumterville">Sumterville</option><option value="Winter Garden">Winter Garden</option><option value="No Preference/Not Sure">No Preference/Not Sure</option></field><field type="select" name="area-of-interest" label="Select Area of Interest"><option selected="true" value="">Select Area of Interest</option><option value="Clinical Dermatology">Clinical Dermatology</option><option value="Cosmetic Dermatology">Cosmetic Dermatology</option></field><field type="select" name="existingpatient" label="Existing Patient?"><option selected="true" value="Established Patient">Established Patient</option><option value="New Patient">New Patient</option></field><field type="date" name="date" label="Appointment Date"/><field required="true" type="select" name="appointment-time" label="Appointment Time"><option selected="true" value="8:00-8:30">8:00-8:30</option><option value="8:30-9:00">8:30-9:00</option><option value="9:00-9:30">9:00-9:30</option><option value="9:30-10:00">9:30-10:00</option><option value="10:00-10:30">10:00-10:30</option><option value="10:30-11:00">10:30-11:00</option><option value="11:00-11:30">11:00-11:30</option><option value="11:30-12:00">11:30-12:00</option><option value="1:00-1:30">1:00-1:30</option><option value="1:30-2:00">1:30-2:00</option><option value="2:00-2:30">2:00-2:30</option><option value="2:30-3:00">2:30-3:00</option><option value="3:00-3:30">3:00-3:30</option><option value="3:30-4:00">3:30-4:00</option><option value="4:00-4:30">4:00-4:30</option><option value="4:30-5:00">4:30-5:00</option></field><field type="text" name="insurance2" placeholder="What is your Health Insurance?"/><field required="true" type="select" name="preferred-call-time" label="When is a good time to call?"><option selected="true" value="">When is a good time to call?*</option><option value="Morning">Morning</option><option value="Afternoon">Afternoon</option><option value="Evening">Evening</option></field><field type="textarea" name="comments" placeholder="Enter any comments or questions here..." label="Comments"/><field type="hidden" name="rendered-form" value="is_rendered"/></fields></form-template>

Upon submission, a representative will contact you during normal business hours to confirm your request.

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