Patient Information Form

Tele-Health Patient Information Form

You may choose to pay on the website or you may forego payment and we will call you to take payment over the phone once the form is received. After payment, we will contact you and set up a convenient time for the tele-health visit. If you care to call us prior to making the deposit please call 774-615-5204 or use the live chat on this page.

Click here if you prefer to have an in-office appointment.

Please call 617-787-7400 if you have not been contacted within 2 hours of submission

Your security is important to us. We do not store your credit card information. Online payments are passed via a secure socket layer to a payment processor where your information is tokenized (whereby a random number is generated to represent your payment). The payment processor is PCI compliant which ensures that your information is being handled in accordance with industry security standards. 

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