Select the type of Specialty you need to get started.
Behavioral Health
Psychiatry and Psychology
All Other Specialties
e.g. Endocrinology, Dermatology etc.
US Licensed Medical Providers
100% Secure and Confidential
Book a Specialist appointment today.
Please fill in the form below.
Personal details
Legal First name*
Legal Last name*
Mobile*
Email address*
Gender at birth*
Male
Female
Referred by*
Web search
Insurance company
Friend and family
Therapist
Medical professional
Existing patient
Other
Address*
City*
State*
Zip code*
Emergency Contact Name*
Phone No
Emergency Contact Relationship
Please upload a picture of the front and back of your insurance card.
Upload front of your insurance card
Upload File
Max file size 10MB.
Uploading...
fileuploaded.jpg
Upload failed. Max size for files is 10 MB.
Upload back of your insurance card
Upload File
Max file size 10MB.
Uploading...
fileuploaded.jpg
Upload failed. Max size for files is 10 MB.
Date of birth*
Name of person completing form and relationship to patient*
Reason for appointment*
Current medications and dosage*
List any medical allergies*
Primary Care Physician (Name, Phone, Address)
Preferred Pharmacy
Name
Phone No
Address
City
State
Zip
Is patient a minor?*
Yes
No
Is patient a minor?*
Married
Separated
Divorced
Patient not a minor
Legal Guardian(s) (if applicable)
Preferred Phone No
Cell
Home
Work
Secondary Phone No
Cell
Home
Work
Email Address
Patient/Guardian's Name
Patient/Guardian's Signature
Date
Do you have any current or pending legal issues or are being advised by a court judge,parole officer, or CPS to seek mental health care or assessment?*
Yes
No
Please select if you have ever experienced or suffered from any of the following in the past or present? (check one or all that applies)
Thoughts of harming others*
Past
Present
No
Suicide ideation*
Past
Present
No
Alcohol abuse*
Past
Present
No
Substance abuse*
Past
Present
No
Are you using insurance?*
Yes
No
Insurance provider*
Insurance provider*
Group #(if applicable)
Please upload a picture of the front and back of your insurance card.
Upload File
Max file size 10MB.
Uploading...
fileuploaded.jpg
Upload failed. Max size for files is 10 MB.
Consent
I agree to the TeleMed2U
Terms & Conditions
,
Telehealth Consent
,
Privacy Policy
and
Notice of Privacy Practices
, and understand all of these can be accessed at any time on
telemed2u.com
.
Disclaimer: Self-paying patients have to pay their balance prior to their appointment.
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
Contact Us
3400 Douglas Blvd.
Suite 225 Roseville, CA 95661
Phone:
(855) 446-8628
Email:
info@telemed2u.com