I am 18 years old or older.
I can provide proof of my identity.
I have read and understand MIMPC's Terms and Conditions and Privacy Policies.
I have read and understand MIMPC's Telemedicine Consent Form and I give my full consent to participate in electronic medical assessments and consultations.
I understand that this service does not and should not take the place of my regular check ups with my doctor.
I understand that should I learn of any serious developments in my health it is my responsibility to follow up with my doctor as soon as possible.
I am currently located or will be located in the same state as my MIMPC doctor at the time of my evaluation.
I will not use this service for medical emergencies nor to address any life-threatening condition.
I have completed a New Patient Welcome Form. I know that without this form MIMPC cannot prepare my electronic chart.
First Name *
Last Name *
Date of Birth *
I accept that entering my name and information below constitutes a signature for this form.