Virtual Visit Pre-Intake

Telehealth Patient Intake Questionnaire

Help us prepare for your virtual consultation. This secure form takes about 5 minutes and ensures your provider can focus on what matters most — your care.

Patient

Symptoms

History

Telehealth

Review

Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

I confirm I am a current Florida resident. Divine Grace Medical serves Florida patients only on a self-pay basis. Telehealth visits outside Florida state lines cannot be conducted.

Questions about your intake or virtual visit? Our care team is here to help.

Call (863) 670-3000