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Coconut Palm Trees

VERO BEACH PRIMARY CARE

Telehealth Medical Assessment For
Vero Beach Primary Care

Please complete the information below so Vero we can review your request and determine whether a consultation may be appropriate.

This form is not for medical emergencies. If you are experiencing a medical emergency, call 911 or seek immediate emergency medical care. Submission of this form does not establish a provider-patient relationship and does not guarantee that treatment will be prescribed.

Personal Information
Date Of Birth
Month
Day
Year
Reason For Visit
Primary Reason For Visit
What Concerns Would You Like To Discuss?
Health Information
Are You Currently Pregnant, Trying To Become Pregnant, Or Breastfeeding?
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