We are pleased to offer virtual appointments to ensure that you can access our services conveniently and safely from the comfort of your own home. Please fill out the following form to request a virtual appointment. Once we receive your request, our team will contact you to schedule the appointment and provide further details.
Patient Information:
Full Name*
Date of Birth*
Phone*
Email*
Address
Reason for Virtual Appointment*
Preferred Virtual Appointment Date and Time:*
Preferred Virtual Appointment Date and Time:*
Preferred Virtual Platform:*
Zoom
Microsoft Teams
Google Meet
Other
Additional Information (optional):
I acknowledge that by submitting this form, I consent to the virtual appointment and agree to comply with all instructions and guidelines provided by the healthcare professional during the appointment.
Signature: *
Date*
If you have any questions or need further assistance, please do not hesitate to contact us at +1 984-322-1940 or millerconciergept@gmail.com
We would like to know how you heard about us.
WOM
LinkedIn
Heard on TV
Event Sign Up
Returning Patient
Blog or Publication
Search Engine (Google, Yahoo, etc.)
Social media (Facebook, Instagram, etc.)
Recommended by a friend or colleague
Others:
If referred by a friend, please provide your friend's name:
Submit Request