Patient Resources

New Patient Info

All new patients must complete the patient information form. We have worked hard to make this as easy as possible and give you 2 options to complete this form.

1) Click here to complete the form online using our secure google form

2) Click here to download and print a PDF version that you can complete and return via fax to (351) 207-3963 or by email to [email protected]

Medical History

In addition to the Patient Information Form all new patients must complete the medical history form. We have worked hard to make this as easy as possible and give you 2 options to complete this form.

1) Click here to complete the form online using our secure google form

2) Click here to download and print a PDF version that you can complete and return via fax to (351) 207-3963 or by email to [email protected]

Contact Balanced Telemedicine Today!

Call

631-521-1683

Fax

351-207-3963