VIRTUAL CHECK IN

Appropriate for:

-Medication refills

-Changes to medications

-A flare-up or change in your medical condition

-Asking us to fill out a form

-Check in with a provider

-LYDIA WILL NOT CALL ANY STIMULANT OR CONTROLLED SUBSTANCE IN FROM THIS REQUESTED FORM. IT WILL BE DELETED. PLEASE DO NOT SUBMIT.

-If your description of issue is over two sentences long, you should schedule an appointment. This is for short requests only.

I understand my insurance will be billed for this service with response by a provider.*

First and Last Name

Date of Birth

Sex Assigned at Birth*

Over 45 yrs old?*

Last Annual Physical?

Do you have or suspect you have Ehlers-Danlos Syndrome?*

Condition

Status *

Current Treatment for Condition

I Am*

I Need Refills*

Follow-Up Schedule I'm On:*

Over the last 2 weeks, have you had little interest or pleasure in doing things or feeling down/depressed?*

Other Comments for Lydia

Please upload any relevant documents/photos

Drop your files here to upload

I would like: *

I am interested in an appointment in person or by telehealth*