Patient Enrollment Form - Richard Telehealth

Patient Enrollment Form

Richard Kevin Baker, Nurse Practitioner - Richard Telehealth

I. Patient Information

Full Name *

Date of Birth (MM/DD/YYYY) *

Gender Identity *

Preferred Pronouns

II. Contact Details

Primary Phone Number *

Email Address *

Mailing Address

City

State

ZIP Code

Preferred Contact Method

III. Emergency Contact

Full Name

Relationship

Phone Number

V. Health Information

Currently under care of physician/mental health professional

If yes, please explain

Taking medications or supplements

If yes, please list

Recent surgeries, diagnoses, or major health concerns

If yes, please describe

Currently pregnant

Not applicable

Book Appointment CTA

Ready to start your virtual health journey?

📧 inffo@richard.telehealthpractices.com

📱 Text/Call: 417-224-5194