Metro now accepting TeleHealth for new patients

How does TeleHealth work?

Telehealth can be accessed from anywhere across all types of mobile devices – smartphone, tablet, and desktop or laptop computer. Routine appointments or non-urgent healthcare are now available via TeleHealth appointments with Metro Community Health Service. You don’t need complicated equipment to be able to have a TeleHealth visit.

Please fill out our general consent form first before filling out a telehealth request.

General Consent Form

Please sign our General Consent form before you contact us via TeleHealth.

CONSENT TO TREAT

1 file(s) 221.12 KB

Download

Please fill out this general consent form before you request a Telehealth

Telehealth Visit Request

Requesting Telehealth Services for: (check all that apply)
Primary CarePsychiatryNeurology

Have you been seen at Metro Community Health Centers before?
YESNO

Full Name:

Home Address:

City:

State:

Zip:

Date Of Birth:

Primary Insurance:

Primary Insurance ID Number:

Secondary Insurance:

Secondary Insurance ID Number:

Phone Number for Telehealth Visits:

Email Address for Telehealth Visits:

Name of Caregiver or Scheduling Contact:

Caregiver or Guardian Name:

Care Manager Name:

Care Manager Email:

Care Management Organization:

Does patient reside in group home?
YESNO

If Yes, Name of Agency:

Pharmacy:

Pharmacy Phone Number: