Patient Name*

    Patient Date of Birth*

    Name of Person Completing Assessment*

    Relation to Patient*

    Your Email*

    Phone number for return call/telemedicine visit (mobile phone required)*

    Check the appropriate box(es) if anyone in your household has any of the following:*

    Check the appropriate box(es) if anyone in your household has had any of the following:*

    Please let us know which method you would like for follow up:*
    Telephone call with an AFM Registered Nurse (audio only)Secure Telemedicine Visit with an AFM Board Certified Provider (audio & video required and we will bill insurance for these visits)

    Please use this field to note any other pertinent information.