Name *

First Name

Last Name

Phone

(###)

###

####

Telehealth Consent Acknowledgment *

By submitting this form, I acknowledge that I am requesting a telehealth consultation with Remedy Skin, Hair, and Wellness. I understand that telehealth involves the electronic communication of my medical information for assessment, diagnosis, and treatment planning. I further understand that I will receive a detailed Telehealth Consent Form to review and sign before my consultation is confirmed.

I acknowledge and agree to proceed with the telehealth consultation request.

Restrictions on location

I am currently located in NC at the time this consultation is being conducted

How did you hear about us? *

Calling my office

Referral

Facebook

Instagram

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Word of Mouth