Virtual Healthcare Services Agreement for Diabetes Care

Electronic Medical Consultation

All conditions rates start at $39. No insurance is required.

Before You Continue - Please Review Our Informed Consent Agreement
By continuing this process and clicking next below, you are indicating that you have read and agreed to our terms of use and privacy policy. These documents include information about relevant terms and conditions in detail. Some basics include:
- In order to use our site, you must be 18 years of age or older, and by continuing this process and clicking next below, you affirm that you are at least 18 years of age.
- Additionally, you acknowledge that you understand you’re engaging in an online medical consultation and that you hereby consent to receive healthcare services from one of our medical providers (MD, PA, NP, or DO).
- You understand that our healthcare providers reserve the right to deny care for any reason.
- You acknowledge that you have a complete understanding of the risks and advantages associated with online medical consultations.
- You acknowledge that you have a complete understanding of the risks and advantages associated with online medical consultations.
Disclaimer Agreement*
- I have read and agree to the informed consent agreement.

Please explain why you need this lab test:*
Do you have any medical conditions?*
- Yes
- No
Please explain:*
Are you pregnant or breastfeeding?*
- Yes
- No
Would you like to choose your lab center?*
- Yes
- No, refer me to the lab center closest to me.
Lab Center Name*
Lab Center Address*
Street Address Address Line 2 City State ZIP
Lab Center Phone*
Do you want a copy of your imaging/lab result sent to your PCP?*
- Yes
- No
Physician Name*
Physician Address*
Street Address Address Line 2 City State ZIP
Physician Phone*
Phone
This field is for validation purposes and should be left unchanged.

Before You Continue - Please Review Our Informed Consent Agreement