Book a Specialist appointment today.

Please fill in the form below.

Personal details

MaleFemalePrefer not to say

Appointment type *Initial consultation visitFollow-up visit

How would you like to pay for the visit? *Self PayInsurance

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.

Preferred method of contact

EmailPhoneText

How did you hear from us?

Web SearchPrimary Care ProviderOther Medical ProfessionalInsurance CompanyFriend or FamilyExisting PatientAnother WebsiteEmail NewsletterBlue Shield MemberOther

Are you using insurance?*YesNo

Insurance provider*Insurance ID*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.

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

ConsentI 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