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Patient Information & Authorization

Please click or tap each field below and type your information. For security, enter only the last four digits of the payment card. Do not enter a full card number, expiration date, or security code on this form.
Patient Name Date of Birth Name on Card Card Type Last Four Digits of Card Only Patient/Authorized Representative Signature (type full legal name): Date Submit

If Signed by Someone Other Than the Patient
Name of Authorized Representative Relationship to Patient Authority to Sign on Patient's Behalf Authorized Representative Signature (type full legal name) Date
SMS opt in
I agree to receive SMS/text messages from Call Doctor Packer Telemedicine regarding services, scheduling, and account updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance. Consent is not a condition of purchase.
Submit

Electronic Signature Notice

Typing a full legal name in a signature field is intended to serve as an electronic signature and acknowledgment of this
agreement. The practice may retain the completed electronic form as part of the patient's records.
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