Fast & Convenient Telemedicine Primary Care

This short signup form will guide you through a few easy to follow questions to get you scheduled for a telehealth virtual consult with Defy Medical for Primary Care services in about 5 minutes.

Your virtual consult includes video chat (with telephone fallback) with a Defy Medical provider who will assess your symptoms and medical history and provide you with a treatment and recommendation plan. Our low price includes calling in any prescriptions that are deemed appropriate to a local pharmacy of your choice.

* indicates a required field.

1. Your Information

Please tell us about yourself and enter a phone number and email address so that we may contact you.

First Name *

Last Name *

Date of Birth *

Gender *

Phone Number *

Email Address *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

When would you prefer an appointment? *

Are you already a Defy Medical patient? *

Yes

Please enter your Primary Care Provider (PCP)'s name and phone number if you have one.

PCP Name

PCP Phone Number

4. Local Pharmacy

Please enter the name, address, and phone/fax for the pharmacy where you want any prescriptions to be called in that are deemed appropriate for your symptoms.

Note: A virtual consult is not a guarantee of a prescription.

Pharmacy Name *

Phone Number *

Fax Number *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

5. Payment Information

Your credit card will be charged one time for a total of $39.00 for the virtual consult.

First Name *

Last Name *

Card Number *

Exp Month *

Exp Year *

CVV *

Billing Zip Code *

6. Consent to Treat

I hereby request, consent and authorize Defy Medical's practitioners to consult, diagnose and treat my health care condition related to general primary care services.

I understand that it is my sole responsibility to communicate and provide my practitioner accurate and complete information related to my medical care including but not limited to medication history, allergies to medications, related symptoms and conditions and any other information pertinent to the diagnosis and treatment of my complaint.

I consent to being treated by Defy Medical without an initial in-office physical exam (in the case of a telemedicine visit) and that the physical examination portion of this service, if any, may be delivered via "telemedicine" or "telehealth" in reliance upon either video, photos, telephone or video consultation, questionnaire and/or medical records.

I acknowledge that I am receiving general primary care services through Defy Medical that are not intended for emergency conditions. I will contact the appropriate emergency medical personnel should I need any emergency medical assistance or encounter any serious or concerning symptoms.

I understand that all services provided by Defy Medical are self-pay and will not be billed to any third-party insurance providers.

I understand that I may contact my primary care physician at any time before starting any prescription medication to confirm that my physician approves of my prescribed regimen. It is my responsibility to keep all practitioners involved in my care aware of my current medications, treatments, procedures, etc so that medication interactions and adverse outcomes can be minimized.

I understand that the Defy Medical practitioners may refuse to treat my medical condition if, in their medical judgment, it is determined that it would be unsafe or inappropriate to treat my condition via telemedicine or our primary care platform. In most cases, this includes a policy to not prescribe controlled substances via the primary care service.

I understand that this service is not for treating Hormone Replacement Therapy (HRT) or side effects from HRT/TRT..

I understand that no controlled substances classified as Schedule II by the DEA will be prescribed.

I understand that this service is not for the treatment of pain management and that no pain relievers or classes of drugs for treating pain such as opiates will be prescribed.

I understand that this service does not assess, test or diagnose patients who believe they may have contracted COVID-19. If you suspect you have or have been exposed to COVID-19, please contact your local health officials for information on local testing and precautions.

I verify that the information entered is accurate to tbe best of my knowledge and I agree to the terms and conditions stated above. *

Pay $39.00

This short signup form will guide you through a few easy to follow questions to get you scheduled for a telehealth virtual consult with Defy Medical for Primary Care services in about 5 minutes.

1. Your Information

We treat these common symptoms through our telehealth virtual consults. Symptoms that are not on our list may not be treatable using a telehealth virtual consult.

The provider who does your virtual consult needs to know about your medical history and health by completing the questions below.

Please enter the name, address, and phone/fax for the pharmacy where you want any prescriptions to be called in that are deemed appropriate for your symptoms.

Your credit card will be charged one time for a total of $39.00 for the virtual consult.