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Complete Your Secure Patient Intake

This takes less than 2 minutes and helps your provider prepare for your visit.

Your information is safe and protected. This secure form allows our

licensed Nurse Practitioner to understand your symptoms and provide the best

possible care during your virtual visit.

First Name *

Last Name *

Date Of Birth *

State You Are Currently Located In *

Florida

Louisiana

Connecticut

Massachusetts

California

New York

Washington

Phone *

Email *

Preferred Pharmacy (Name, City, State) *

What is the main reason for your visit today? *

How long have you had these symptoms? *

How would you rate your discomfort right now? *

Mild (1-3)

Moderate (4-6)

Severe (7-10)

Have you tried any home treatments for this issue? *

Have you been seen for this issue before? If yes, what was the diagnosis/treatment? *

Do you have any current medical conditions? *

diabetes

hypertension

asthma

None

List all current medications (including vitamins and supplements) *

Do you have any known drug allergies? *

Are you pregnant or breastfeeding? *

Yes — Pregnant

Yes — Breastfeeding

Not Applicable

Do you smoke or use tobacco products? *

Yes — Current

Yes — Former

I understand this is a self-pay visit and payment is collected at the time of booking. *

I agree

I understand this is virtual urgent care and not a replacement for emergency services. I will call 911 if I experience a medical emergency. *

I agree

I consent to telehealth services and understand my visit will be conducted via secure video call. *

I consent

I have read and agree to the Proficient NP Privacy Policy and Terms of Service. *

I agree

How did you hear about Proficient NP? *

Google Search

Social Media

Friend or Family

Online Ad

Other

This form is HIPAA-compliant and your information is protected.

Proficient NP will never sell or share your personal health information.

If you are experiencing a medical emergency, stop and call 911 immediately.

Questions? Contact us at 561-300-6823 or [email protected]

561-300-6823

[email protected]