EXPHS eVisit Registration

eVisit Registration

EXPRESS HEALTH SYSTEMS

A $25 deposit is required to schedule a reserved appointment time. Payment information will be collected upon the completion of online forms.

The $25 required deposit will be waived in the event of a previously funded yet unused deposit.

FAILURE TO USE THE CORRECT spelling of your first and last name, as well as your documented date of birth, will result in the inability to schedule an appointment online.

Deposit FAQs

Why are we collecting a deposit?

Once you make an appointment that date and time is blocked for you alone. Another person cannot book an appointment for the same date and time that you have reserved. Once you have made a reservation, we must schedule staff members to be available to see you at that time. If at the last moment you fail to show up for your appointment, no other person has time to fill your date and time reservation, yet we still incur staffing cost. This is not fair to other patients that would have wanted to be seen during the appointment date and time that you reserved. It also creates an unfair financial burden to our company.
What happens to my deposit?

If you show up for your scheduled appointment, your deposit will be applied towards your visit's expense.
Under what circumstances would I lose my deposit?

If you fail to show up to your scheduled appointment date and time, you will lose your deposit. If you fail to have ALL of the necessary equipment (Photo ID, Digital Blood Pressure Cuff, scale, and measuring tape), then you forfeit your deposit. Please note that we monitor prescription controlled substances and that we CANNOT prescribe appetite suppressants if you are actively taking any medications for ADD/ADHD.
Under what circumstances can I get my deposit refunded to me?

If you cancel or reschedule your appointment date and time more than 72 hours prior to your reserved date and time appointment, your deposit will be refunded to you or applied towards your new scheduled appointment date and time. If, however, you reschedule or cancel your appointment three times in a row, you will lose your deposit regardless of how far out you cancelled or rescheduled the appointment.

eVisit Form

Please select the state of the pharmacy your script will be sent to: *

Selecting a state serves as an acknowledgement that you will be located in the selected state at the time of your eVisit.

Based on the State that you selected that your prescription(s) will be sent, we offer the following eVisit Services:

Patient Information

Patient Name *

First Name (as appears on License/Identification)

Last Name (as appears on License/Identification)

Middle Name (optional)

Maiden Name (if applicable)

Date of Birth *

Patient Information

Address * Street Address

Apt #/Suite/Other (Optional)

City

State

ZIP Code

Gender *

Female

Male

Email Address *

Phone Number *

If you wish to receive any information or promotions from Express Health Systems: No Thank You Email Text (carrier charges may apply) Mail

Current medications, supplements, vitamins, or herbs

Care Providers

Do you have a Primary Care Provider(PCP) and/or any other medical specialist/s? *

Yes

No

Name of Provider *

First Name of Provider

Last Name of Provider

Is this your PCP? *

Yes

No

Practice Name *

Specialty *

Practice Location *

City of Practice

State of Practice

Do you give us permission to share our visit information with this provider? *

Yes

No

Do you give us permission to obtain medical records from this provider? *

Yes

No

Medical History

Social History - Check all that apply: *

None Cigarettes Smokeless Tobacco Alcohol Consumption Illicit Drugs

Review of Symptoms - Check all that apply: *

None Swelling Fatigue Skin, Hair, or Nail Problems Excess Weight

Eating Habits - Check all that apply: *

None Large Portions Sweets/Snacks Carbonated Drinks

Allergies to Medications - Please List:

Physical Activity

Do you exercise? *

Yes

No

How many days per week? *

1 2 3 4 5 6 7

How long do you exercise? *

30 minutes

30-60 minutes

> 60 minutes

What kind of exercise do you do? *

Walking Jogging/Running Mixed cardio Swimming Other

We are currently accepting Patients into our Virtual Waiting Room. Would you like to be put into our Virtual Waiting Room or Schedule at future date and time? *

Virtual Waiting Room

Schedule Future Date & Time

Prepare for eVisit Checklist

Please make sure you use the calendar scheduler after you submit the eVisit form. If you do not schedule an appointment you will not be seen. Thanks.

Please make sure you are prepared with the following items prior to your scheduled eVisit time:

Digital Weight Scale
Measuring Tape for Hip and Waist Measurements
Digital Blood-Pressure Cuff (wrist-cuff is permissible)
Video-enabled device
Photo Identification (valid government-issued ID)

I understand

eVisit Registration

Deposit FAQs

eVisit Form

Based on the State that you selected that your prescription(s) will be sent, we offer the following eVisit Services:

Sorry, we do not currently offer any eVisit services in your state. Please check back at a future date for any changes.

Patient Information

Patient Information

Care Providers

Medical History

Physical Activity

Terms & Conditions of Service

Prepare for eVisit Checklist

Payment