New Patients | My Site

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NEWSLETTER

ABOUT

To become a TeleMedicine patient please fill out this form.
When complete, Hit the SEND button.
We will contact you to set up an appointment.

First name

Date of Birth: MM/DD/YYYY

Last name

Sex

Male

Female

Street Address

Street Address Line 2

City

State

Zip code

Primary Phone

Alternate Phone

Your Email

I give permission for Advanced Medical Care to send text messages to my Primary Phone.

YES

I give Advanced Medical Care permission to leave content messages by: (check all that apply)

Text to my Primary Phone

Voicemail to my Primary Phone

Insurance Company Name

Patient Insurance ID Number

Social Security Number

TeleMedicine Informed Consent. You need a Primary Care Provider in addition to Advanced Medical Care, and access to a cellphone or computer with a webcam. TeleMedicine has the disadvantage of no in person exam, but has the same privacy as in person visits. Please type your name below to indicate you understand and agree to the above and give your consent to do TeleMedicine visits.

Please provide the email address that you want us to send the link to for the TeleMedicine visit.

Reason for Coming In

Anything Special We Need To Know About You or Your Medical Condition

I take prescription medication for the following conditions: (check all that apply)

Heart disease

High blood pressure

Asthma or COPD

Arthritis/fibromyalgia

Insomnia

Depression or anxiety

Headaches or migraines

Diabetes-I do NOT take insulin

Diabetes-I DO take insulin

We will contact you to schedule your appointment.

Three things you need for your TeleMedicine appointment.

1. You should be in a private place at the time of the appointment.

2. A cell phone, tablet, laptop or desktop computer with a webcam.

3. All current medication bottles, OTC and prescription, even if the bottles are empty.

If you have any questions call 360-264-2492, or use the Contact Form below.

Advanced Medical Care

PO Box 822

Rainier WA 98576

Appointment Times Vary. To schedule a TeleMedicine appointment, call:

360-264-2492

Medical Fax: 833-694-1504

To check in for TeleMedicine

Appointment go to:

Doxy.me/cwjasper

Or use this button:

Or use QR Code below:

TeleMedicine Visit

For Any Questions Contact Us Here

First Name

Last Name

Add message or question here. Include your phone number if you want a call back.

Thanks for submitting!

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To become a TeleMedicine patient please fill out this form. When complete, Hit the SEND button. We will contact you to set up an appointment.

For Any Questions Contact Us Here

To become a TeleMedicine patient please fill out this form.
When complete, Hit the SEND button.
We will contact you to set up an appointment.