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PHARMACIA TELEHEALTH SERVICE

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Telehealth Appointment

Verify your contact information. We’ll send a secure verification code, then you can book your consult in under 2 minutes.

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This service its brought to you by Pharmacy name & Pharmacia Telehealth . By continuing you agree to all terms and conditions (link).

If you prefer the e-prescription token to be send to you please use our general telehealth service at [website.com].

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Personal Information & Symptoms

Please provide your details and describe your symptons

Personal Details

First Name *

Last Name *

Phone *

Email *

Date of Birth

Gender *

Title *

Address *

City

state

Post Code

Medicare Details

Do you have medicare card?

Symptoms & Medical Information

Current symptoms or consult reason *

Allergies *

Current Medications *

I declare that the information in this form is true and accurate and I have read and accepted Pharmacia Telehealth Terms and Conditions and consent to the use of information in accordance with the Privacy Policy

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