Telehealth

Telehealth is healthcare using secure phone or video conferencing. We are transitioning all medical services that do not require an in-person visit to telehealth. This will allow us to support social distancing while providing access to medical care during the Covid-19 pandemic. Patients are able to access care from a WeARE provider via a smartphone, tablet, or computer. Telehealth visits can be billed to insurance or paid for using our sliding scale fees. Please complete the form below then click on “make an appointment” or call 454-1546 or text 838-6280 to speak with WeARE staff.

Telehealth Form

Please fill out the following form prior to your appointment.
Upon submission, you will be redirected to our appointment page,
where you will need to request a telehealth appointment.

By filling out the form below, you acknowledge that you have read and understand
our HIPAA/Privacy form and our Telehealth Services policy.

First Name

Last Name

Date of Birth (MMDDYYYY)

Email

Is it okay to email you?

Phone

Is it okay to call/text you at this number?

Address

City, State & Zip Code

Is it okay to send mail to this address?

What is your yearly income?

Gender at Birth

I identify my gender as...

I partner with...

Are you Latino or Hispanic?

What is your Race?

What services do you need an appointment for? (ex. birth control, STI testing, pregnancy testing, etc.)

What is the name of your insurance company? (If none, please state.)

Where did you hear about WeARE The Clinic?

Consent Consent I have read and understand the WeARE HIPAA policy linked here. I consent to WeARE Telehealth Services as outlined in this linked document.

Please write your full name here as an electronic signature to to the forms linked above.