Telemedicine Pre-Registration

If you have already registered, you may log on by clicking on this link:

    Please fill out the details in the form below to enroll the student in the Telemedicine Program

    Por favor, rellene los detalles en el siguiente formulario para inscribir al estudiante en el Programa de Telemedicina

    Patient InformationInformación del paciente


    Parent/Guardian Information Información de los padres

    (Only if different than the student's address)

    Emergency Contact / Contacto de Emergencia

    (only add if different than the Primary Guardian)

    Medical History / Historial Medico

    Please indicate NONE if the child is not taking any medications

    Patient Insurance / Seguro del paciente

    Preventive Health Solutions