ADULT REMOTE VISIT

This form is appropriate for patients 18 years of age or older and must be received prior to your appointment. We prefer that you complete the form on this page. Alternately, the linked forms can be emailed to our office at omason@attention.md or faxed to (877) 411-1871. If you use a word processor other than Microsoft Word, remember to save the completed form in .doc or .pdf format.  Please do not send forms in the Mac formats.

(Word DOC form)   (PDF form)

A web form is now available below which allows you to fill out & submit directly online.

Please note that you will need to enter pulse and weight. If you have a blood pressure reading from a recent doctor visit or a home BP machine please provide that information.

We must have the form prior to the appointment time.  Without it, Dr. Mason cannot begin your visit. It would be considered a no show and incur a fee.

WEB FORM

CONFIDENTIALITY NOTICE: Email and text messaging systems do not meet the level of security recommended in the HIPAA legislation.  We make these forms of communication available to individuals who prefer convenience at the expense of security.  Phone and fax communications satisfy HIPAA regulations and are preferred for those who require this standardized level of privacy.