TeleClinicz EMR

Dashboard
Messaging
Appointments
New SOAP Note
Check-In
Admin Panel

Dashboard

JD

Patient Self Check-In

Complete this form on your device to expedite your visit.

Patient Self Check-In

Complete this form to expedite your check-in process.

Contact Information (Optional Updates)

Phone

Email

Address

Visit Information

Current Symptoms*

Reason for Visit (if different from symptoms)

Current Medications (name, dosage, frequency)

Known Allergies

Consents

Consent to Treatment*

I consent to receive medical treatment from TeleClinicz EMR providers.

HIPAA Acknowledgement*

I acknowledge I have been provided with the Notice of Privacy Practices.