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Appointments Request Form
+ EXISTING PATIENTS
+ BOOK COVID-19 TEST

New Appointment Request:

Date of Birth:

 

NOTE: Your provider will call and triage your medical needs and decide BEST TREATMENT OPTION and LOCATION.

Add Billing Method / Credit Card on File:

Your credit card WILL NOT BE CHARGED without prior discussion and approval.

*If international credit card enter "111" for zip code

 

 

If having any trouble booking on-line please call or text 888-663-6631 (888) MODO-MD-1 for assistance.

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