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KID TELEHEALTH

online doctor visits



Kid TeleHealth Visit Request Form

(Fill. Submit. Done.)


Date: *
CalendarNow


Please contact me so I can schedule a Kid Telehealth virtual office visit.
 
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(Type your first and last name.)
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(Provide your preferred phone number where we can reach you.)
This is my: *





(Provide another phone number where we also might reach you.)
This is my:



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Preferred Days:





(Choose which days of the week you'd prefer for your Kid Telehealth visit.)
Preferred Time of Day:




(Choose which times of day you'd prefer.)
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By signing this form (typed signature), you are certifying the accuracy of this information and agreeing to send the information to Madison Pediatrics, Inc. for inclusion into your child's records and requesting Madison Pediatrics to contact you.
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If your form submits correctly, you'll see a confirmation page and we'll respond within 1 business day!