Request An Appointment

Your Name (required)

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How Can We Help? (required)

What medications are you currently taking? (required)

Do you have any preexisting conditions? Please list them and when they started. (required)

Do you have any allergies? (required)

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What allergies do you have? (If none, leave blank)

Are You Looking for a Pain Management or Primary Care Appointment?

Primary CarePain Management

Are You Looking For A Doctor That Speaks English Or Spanish?

EnglishSpanishEitherBoth

Are You Looking For An In-Person or Telemedicine Visit? Please note most pain management visits cannot be done by telemedicine.

In-PersonTelemedicine

Please read and check that your understand our no-show policy

I Have Read & Agree that: We, at Emed Multispecialty Group, understand that sometimes you need to cancel or reschedule your appointment and that there are emergencies. If you are unable to keep your appointment, please call us as soon as possible (with at least a 24-hour notice). For your convenience, there are several options available to cancel your appointment. (1) Call us at (904) 206-7132 during our normal business hours. (2) If you call after hours, our after-hour phone service is available to assist you. (3) Download the HEALOW app for access to cancel or make an appointment. To ensure that each patient is given the proper amount of time allotted for their visit and to provide the highest quality care, it is very important for each scheduled patient to attend their visit on time. As a courtesy, we will attempt to send an appointment reminder call/text at least (1) business day prior to your scheduled appointment. Please ensure we have your updated phone number on file. However, it is the responsibility of the patient to arrive for their appointment on time. PLEASE REVIEW THE FOLLOWING POLICY: • Please cancel your appointment with at least a 24 hours’ notice: There is a waiting list to see the Providers at Emed and whenever possible, we like to fill cancelled spaces to shorten the waiting period for our patients. • If less than a 24-hour cancellation is given this will be documented as a “No-Show” or “Late Cancellation” appointment and will be assessed a $20.00 no show or late cancellation fee. I have read and understand Emeds No Show/Late Cancellation Appointment Policy and understand my responsibility to plan appointments accordingly

I Understand and Agree

Please read and check that your understand our telemedicine policy

I Have Read and Agree that: Telemedicine is the delivery of health care services using interactive audio and/or video technology, where the patient and Provider are not in the same physical location. During your telemedicine consultation with a Provider, details of your medical or health history and personal health information may be discussed using interactive audio, video, and/or other telecommunications technology, and the Provider may perform a physical exam through these technologies. Depending on your medical or health history and/or specific complaint, you may be asked to provide information through other electronic means and verify your identity with a driver’s license or other legal document. The telemedicine services you receive from Emed Multispecialty Group are not intended to replace a primary care physician relationship, be your permanent medical home, or be used during a medical emergency. If you think you are having a medical emergency, you should dial 911 immediately. You should seek emergency help or follow-up care when recommended by a provider, symptoms worsen, or when otherwise needed, and continue to consult with your primary care physician and other health care professionals as recommended. We may make arrangements for follow-up care either through Emed Multispecialty Group, your primary care provider, or other health care providers. If the transmission fails during your telemedicine consultation with a provider, then every attempt will be made to contact you to help you get reconnected. You will have direct access to Healow and Emed Multispecialty Group services to follow-up on medication reactions, side effects, or other adverse events. Among the benefits of Emed Multispecialty Group via Healow is improved access to health care professionals and convenience. However, there are potentials risks associated with the use of telemedicine. These risks include, but are not limited to: 1. In some instances, the information transmitted may be of insufficient quality to allow for appropriate medical or health care decision making by the Provider (i.e., poor resolution images, etc.) 2. Delays in evaluation or treatment could occur due to failure of the electronic equipment; 3. In some instances, a lack of access to all of your medical records could result in adverse drug reactions or allergic reactions or other judgment errors; 4. Although the electronic systems we use will incorporate networks and software security protocols to protect the privacy and security of health information, in some instances, security protocols may fail and cause a breach of privacy and/or personal health information. I, (Patient Name) have read the information, or have had it read to me, and have received a copy of this agreement. I understand my responsibilities and agree to the above conditions while receiving opioid medication.

I Understand and Agree