Telemedicine New Patient Checklist:
- AN APPOINTMENT: You will need to call the office 919-367-3625 to be scheduled for an appointment for telemedicine.
- WHERE YOU WILL CHECK IN: a few minutes before your appointment, click this link to check into the telemedicine portal https://doxy.me/DrChiritescu
- TEST YOUR AUDIO & VIDEO: Ahead of your appointment, please TEST to see if your camera and audio work, do a test call here If your camera/audio doesn’t work, please try a different device (phone or laptop). OR visit our Telemedicine FAQ here and scroll down to find instructions on how to enable camera/audio access.
- FORMS & DOCUMENTS
- Patient Information Form
- Medical History Form
- Authorization for Treatment of a Minor Form (if new patient is under 18 years of age)
- Notice of Privacy Act (please read, but do not need to print)
- Acknowledgement of Privacy Act Form
- Designated Individuals Authorization Form
- Financial Policy
- For 1st Time Accutane Patients (do not fill out unless applicable): iPledge Consent
- Copy of driver’s license
- Copy of insurance card
- PRESCRIPTIONS: List of prescription(s) and the concentration/dosage you are taking or have taken for the condition(s)
- PHOTOS (with measuring tape in photo if needed): Have several well-lit, in-focus (without blur) pictures of the area(s) of concern. Using natural light to take your photo often helps with getting good photos.
- If you have a spot/mole of concern, please include a measuring tape or ruler in your photo next to the spot showing mm/cm (millimeters and centimeters) so we may know the spot’s size.
- SAVE EVERYTHING TO A ZIP FILE: Please save all the above documents in 1 file on your computer. In order to do this, have all your documents in one folder, then click and select all the files , right click and select ‘send to’ and then click ‘compressed (zipped) folder.’ This zipped file will be what you send us in the appointment.
- ACCUTANE TELEMEDICINE PATIENTS, in addition to the above documents, there are additional documents needed, click here.