What is your relationship to the patient? *

I am the Patient

I am the Legal Representative

I am a Senior Living Community Representative

I am a Family Member/Caregiver

Other (please specify below in the Additional Information box)

Can the patient make their own decisions or is there a Power Of Attorney? *

Makes Own Decisions

Can't Make Own Decisions and Has No Legal Representative

Power of Attorney. Must E-mail POA to intake@doctor2me.com or Fax to 818-798-1644

Patient Legal Name *

First Name

Last Name

Patient Date of Birth *

MM

DD

YYYY

Address *

Home address or where the Patient will be at the time of the appointment(s)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Patient or Patient's Contact Telephone Number *

(###)

###

####

Services/Documents Requested

Doctor Visit

602A

POLST

Admission orders

Medication Reconciliation

TB Clearance (Mobile X-ray: results are 24-48 hrs)

TB Clearance (QuantiFERON: results are 3-5 days))

COVID-19 (PCR or home test)

Follow Up Visit

Other (please use Additional Information box)

Move-in Date

MM

DD

YYYY