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

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 one or all that applies)Thoughts of harming others*PastPresentNoSuicide ideation*PastPresentNoAlcohol abuse*PastPresentNoSubstance abuse*PastPresentNo

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

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