APPOINTMENT FORM: TELEHEALTH Appointment - PART 2 - Galleria Women's Health

Telehealth Appointment Form - PART 2

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Please upload or drag and drop a picture of your Driver's Licence and the front and back of your Insurance Card. (New patients only.)
Insurance details may instead be entered in the fields provided after this step.
Drop files here or
Max. file size: 3 MB, Max. files: 4.
Name of Insurance*
Provider Phone Number
If provider not listed, please provide their phone number from the back of Insurance card.
Insurance Member ID*
Group No.*
Telehealth Appointments No Show / Late Cancellation Policy /Fee
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment in a timely manner, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel and we are unable to schedule you for a visit, due to a seemingly “full” appointment book.
Therefore, in order to continue to better utilize available appointments for our patients in need of medical care, we strictly enforce a No Show / Late Cancellation Policy for Telehealth appointments.
Please read the following agreement carefully and accept the terms by clicking the box that says 'Yes, I understand and agree with the terms and conditions outlined'.
I understand that if I do not cancel my Telehealth appointment at least 24 hours prior to my scheduled time, I will be charged a late fee of $25.00, which is not billed to my insurance.
No Show / Late Cancellation Policy And Fee Consent*
I agree to the 'no show / late cancellation' policy and fee.
Please provide your credit card information for processing the cost of your Telehealth appointment.
Credit Card Number
Expiry Date
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

Your Telehealth Appointment:

Please confirm your name and email, by re-entering them, along with the date of the appointment selected.
Provide the name of your Insurance provider and deductible.
Provide credit card payment details, for processing any payment.
Upload proof of identity (Driver’s Licence, Front & Back of Insurance Card).
Consent to “No Show / Late Cancellation Policy And Fee”.

Once your appointment is confirmed an email will be sent to you along with a website link for your private Telehealth appointment with Dr. Kashyap.

Day of Appointment

On the day of your appointment, please login/register online using the link provided 5-minutes before your appointment time. This will ensure that you are ready to begin your conversation with Dr. Kashyap on time, to ensure your full allotted time is available for your appointment.

Cancellation Policy

Please note, cancellations must be received at least 24 hours before your scheduled appointment. Refunds will not be made for cancellations made with less than 24-hours notice.