US Licensed Medical Providers 100% Secure and Confidential

Book a Specialist appointment today.

For urgent or emergent medical needs, please call 911 or visit your nearest emergency department. Our online appointment request forms are intended for non-urgent appointments only.

Please fill in the form below.

Personal details

For Dermatology visits, you're required to upload 2 high res images of the area of concern.*YesNot Applicable

Upload File

Max file size 10MB.

Uploading...

fileuploaded.jpg

Upload failed. Max size for files is 10 MB.

Gender at birth*MaleFemalePrefer not to say

Date of birth*

Emergency Contact Name*

Phone No*

Emergency Contact Relationship

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

Appointment type *Initial consultation visitFollow-up visit

Is patient a minor ?*YesNoDo 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?*YesNoPlease select if you have ever experienced or suffered from any of the following in the past or present? (check that applies)Have you had thoughts of harming yourself?*PastCurrentlyNeverHave you had thoughts of harming others?*PastCurrentlyNeverHave you struggled with alcohol abuse?*PastCurrentlyNeverHave you struggled with substance abuse?*PastCurrentlyNever

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 170 Roseville, CA 95661

Phone:
(855) 446-8628

Email:
info@telemed2u.com

© 2021 TeleMed2U. All Rights Reserved. • Terms • Privacy Policy • NOPP • Telehealth Consent

If you are actively in crisis, please call or text 988 for the Suicide & Crisis Lifeline. TeleMed2U does not provide emergency or crisis services. For additional immediate support, you can also contact the Revive support at 800-327-2251. By continuing, you acknowledge and consent that you understand TeleMed2U is not a crisis response provider.

TeleMed2U does not provide specialized treatment for Alcohol Use Disorder.

Our clinicians can support underlying behavioral health needs, but we are unable to treat, manage, or prescribe for alcohol misuse. For help with alcohol use, you can contact the SAMHSA National Helpline at 1-800-662-HELP (4357), available 24/7. By continuing, you acknowledge that you understand TeleMed2U cannot treat Alcohol Use Disorder.

TeleMed2U does not provide specialized treatment for Substance Use Disorders.

Our clinicians can support underlying behavioral health needs, but we cannot treat, manage, or prescribe for substance use. For support, you can contact the SAMHSA National Helpline at 1-800-662-HELP (4357), available 24/7. By continuing, you acknowledge that you understand TeleMed2U cannot treat Substance Use Disorders.