Video Visit Request Form

Please do NOT use this request for emergent issues. Call the office for emergent issues.

Patients who have selected Firstcare as their Patient-Centered Medical Home can request video visits with a provider by completing the form below.

Please note, if the reason for your visit request is not appropriate for a video visit, our office will contact you to schedule an in-office visit.

Please complete the form below

* Indicates a required field

Patient's Name

First Name

Last Name

Patient's Date of Birth

MM

DD

YYYY

Patient's Phone Number

(###)

###

####

Email

Preferred Method of Contact

Phone

Email

Preferred Appointment Date

Please enter the preferred date for your video visit.

MM

DD

YYYY

Prefered Appointment Time

Reason for Video Visit

Please provide a brief description of the reason for your video visit request

Additional Comments

Please use the section below to enter any additional information, such as a preferred provider for a non-emergent follow-up request.