eVisit Appointment Request Form *All fields are required ~By submitting the form below, you agree to ExpressCare's Terms and Conditions. First Name * Last Name * Date of Birth * Best Contact Number(s) * Do you use WhatsApp? * Yes No (We may communicate with you using WhatsApp) Which phone number? Your Email Address * Confirm Email Address * Physical Address * (Include: Street, City, State, Country, ZIP Code) Have you been seen at ExpressCare before? * Yes No Do you have allergies to any medicine? * Yes No Which medicine? * Provide a list of all your medicine and dosages. * Which pharmacy do you use? * What is your health concern today? (Provide Full Details.) * Do you have Insurance or will it be Self-pay? * Insurance Self-pay Take a photo of the Front and Back of your Insurance Card and upload it here. Upload Front of Insurance Card * Files must be less than 10 MB.Allowed file types: jpg jpeg png. Upload Back of Insurance Card * Files must be less than 10 MB.Allowed file types: jpg jpeg png. Preferred Date and Time of eVisit Appointment We will try out best to accommodate. First Preference * Time (ChST) * Select10 am11 am12 pm1 pm2 pm3 pm4 pm Second Preference * Time (ChST) * Select10 am11 am12 pm1 pm2 pm3 pm4 pm What code is in the image? * Enter the characters shown in the image.