Patient Intake Form

Welcome to Rei Direct Care and Wellness. To provide you with the most personalized and expert telehealth experience, please share your details below.

Personal Information

First Name

Last Name

Date of Birth

Month

Day

Year

Phone

Email Address

Home Address

Country/Region

Address

City

Zip / Postal code

State

Medical History

Reason for Visit

Current Medications

Allergies

Preferred Pharmacy

Emergency Contact

Please provide an emergency contact in case we need to reach someone on your behalf during a medical concern.

Emergency Contact Name

Emergency Contact Phone

Required Consent

By continuing, I consent to receive telehealth care from Rei Direct Care & Wellness, including evaluation, treatment, and prescriptions when appropriate. I understand telehealth has limitations and is not for emergencies, and I agree to seek immediate care or call 911 if needed. I acknowledge that care is based on clinical judgment, no outcomes are guaranteed, and I agree to provide accurate health information and follow my treatment plan.

I understand my information will be kept private in accordance with applicable laws, and that no system is completely secure.

Date picker

I consent to the terms

Continue to Booking