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Appointments Request Form
+ EXISTING PATIENTS

New Appointment Request:

IMPORTANT: If requesting a medical consultation after hours between 10:00PM and 8:00AM please call 888-663-6631 (after-hours fees may apply).
Date of Birth:

 

NOTE: Your provider will call and triage your medical needs and decide BEST TREATMENT OPTION and LOCATION.

Tell us what you're looking to boost: Energy, Immunity, Cold & Flu, Inflammation, Hangover, Jet Lag, Beauty, NAD+, or Exomes.

Add ons: NAD+, Vitamin C, Glutathion or Zinc, Multi Vitamin, Lysine, MIC, Vitamin B Complex, Magnesium.

MODO Clinic:

My Hotel:

My Home:

TeleMed:

Add Billing Method / Credit Card on File:

Your credit card WILL NOT BE CHARGED without prior discussion and approval.

Are you booking under our MODO For the People program? If yes, please enter "111" for Credit Card information field(s). There will be no charge for qualified patients affected by Lahaina fires.

*If international credit card enter "111" for zip code

 

 

If having any trouble booking on-line please call or text 888-663-6631 (888) MODO-MD-1 for assistance.

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