Telehealth Appointment Form - PART 2

  • MM slash DD slash YYYY
  • Insurance details may instead be entered in the fields provided after this step.
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    • If provider not listed, please provide their phone number from the back of Insurance card.
    • 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.

    • Please provide your credit card information for processing the cost of your Telehealth appointment.
    • 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.


    Questions? Call us at 702-983-2010.


    Dr. Deepali Kashyap, MD FACOG
    Galleria Women's Health
    1389 Galleria Dr, Suite 220
    Henderson, NV 89014
    Phone: 702-983-2010
    Fax: 702-476-9202

    8:30AM - 4:30PM
    8:30AM - 4:30PM
    8:30AM - 4:30PM
    8:30AM - 4:30PM
    8:30AM - 4:30PM
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