Appointments Request Form

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).

First Name

Last Name

Date of Birth:

Month (of Birth):

Day (of Birth):

Year (of Birth):

Address:

City:

State (US & Canada):

Zip Code:

Phone Number:

Email:

Gender:

Male

Female

Other

Medical Reason for Visit:

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

Location for Service:

Do you have any known allergies? Please list. If none, enter "None".

What medications are you currently taking? List all. If none, enter "None".

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.

Name As It Appears On the Card: Credit / Debit Card Number:

Expiration Date:

CVC Code:

Billing Zip Code *:

*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.

Hello and Welcome to MODO Mobile Doctor!

Are you a new or an existing patient?

Date of Birth:

Add Billing Method / Credit Card on File: