Telemedicine appointment - Baz Allergy, Asthma & Sinus Center

Call 911 immediately if you have a medical emergency. Do not rely on communication through this website for urgent medical needs.

Patient First Name

Patient Last Name

Date of Birth

Medical Insurance

Type

No Insurance Existing Patient New Patient

Phone Number

Pharmacy Name

Email Address

Pharmacy Address

Which device are you using for this visit:
(Must have Audio & Video capabilities)

iPhone Android Laptop/Computer

If Other

COVID 19 questions:

Have you been exposed to any one with confirmed diagnosis of COVID-19?

Yes No

Have you traveled outside Central Valley in last 14 days?

Yes No

Have you traveled outside United States in last 14 days?

Yes No

Reason for Calling today (Visit)

Cough Nasal congestion Runny nose Watery & Itchy eyes Hives Rash Itching Other

If Other

Fill any that you can do at home:

Pulse/min:

Temp:

Height:

Weight:

Blood Pressure:

Respiratory Rate/min:

Are you allergic to any medication?

Yes No

If yes

Current medications:

Comments

How would you like to initiate your Telemedicine visit?

Email Text message

Please be advised that by using this link you have provided verbal consent to conduct your visit via video chat. If you do not consent please call office to schedule a regular appointment.

Telemedicine Appointments

COVID 19 questions:

Fill any that you can do at home: