Telehealth Application

This application is the first step in determining whether telehealth care through this practice is clinically appropriate and aligned with your needs.

Please complete the form thoughtfully and completely.

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Full legal name *

First

Last

Preferred name

Date of Birth *

Email address *

Current state of residence *— Select Choice —FloridaVirginiaOther

Eligibility Confirmation (please read carefully) *

• I understand this practice provides non-emergency telehealth care only
• I am not seeking urgent or emergency care
• I understand this practice does not provide labor or delivery care
• I understand submitting this application does not guarantee acceptance
• I understand that education and application review do not establish a patient-provider relationship

Reason for Request (select all that apply) *

• Perimenopause or menopause concerns
• PCOS or hormonalmetabolic concerns
• Menstrual cycle concerns
• Contraceptive counseling
• Sexual or reproductive health education
• Preconception or prenatal planning education only
• Other (please explain)

Other (short text explanation)

Have you completed one of our womens health education programs *

• Yes
• Not yet
• No

Optional: Program completed (if applicable)

Care Expectations (select the statement that best matches your preference) *

• I am seeking education-based, collaborative care with clear scope and boundaries
• I prefer a structured review and education plan, and I understand some needs require in-person care
• I am primarily seeking urgent guidance for a time-sensitive concern
• I am primarily seeking prescription-focused care rather than education-based collaborative care

our completed matches

Scope & Boundaries (required) *

• I understand this practice has a defined clinical scope
• I understand some concerns require in-person care
• I understand telehealth is not appropriate for every condition
• I am willing to be referred elsewhere if needed

Are you currently under the care of another OBGYN or womens health provider *

• Yes
• No

Optional: Prior care context (select any that apply)

• Complementary care
• Transition of care
• Education-only support

Final Acknowledgment (required) *

• I understand my application will be reviewed for appropriateness
• I understand I may or may not be offered an appointment
• I agree to communicate respectfully and within established boundaries

Optional closing question: Is there anything else you would like us to know

Important Notice

Submit Application