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* - GEMB Patients has been acquired by US Tele-Medicine

WELCOME TO YOUR FAMILY DOCTOR AND
GENERAL PRACTICE PHYSICIANS

We Provide You Medical E-Care,
When You Need It and When You Want It.

Welcome! Once you complete the intake forms and join, you will be known as an E-Patient. The marvelous world of medical technology will open for you. Your vital signs can be measured from the comfort and privacy of your home, sent directly to our computers, and that is just the beginning of the medical revolution taking place in America - and now, you are part of it too.

Each participant must register separately, as medical records and e-care are unique to each person, even members of the same family, or organization.

Your information is protected by Medical Privacy Laws. Our advanced EMR (Electronic Medical Records systems) stores you information and these servers are HIPAA compliant, secured, and highly encrypted. We take E-Patient privacy very seriously and we refer you to our Privacy Policy Link found at the bottom of this page for a complete review of our strict guidelines.

Of course as with any medical clinic, you must have insurance to participate. We do accept all major medical insurances including Medicare. In addition, your deductible must be met already before E-Care is provided, or you will be liable. If you are uncertain, call your insurance company for the latest details.

Please be as complete as possible in your answers. The more your Doctor knows about you, the better your quality of your E-Care. Be specific as to your diagnosis, any chronic conditions, use of prescriptions, and alternative/ integrated supplements.

Once you have enrolled, a member of our Medical Team will contact you to confirm your information and discuss any immediate issues that need medical oversight and attention.

Once completed, your information is accessible to you and may be up-dated as needed.

Also, please make note of your Username, Password, and Membership I.D. number.

You may contact a member of our Medical Team at any time - simply click on the Contacts Tab on this web site and select "Medical Team".

WELCOME TO TELE-MEDICINE - THE FUTURE OF HEALTH CARE TODAY!

* denotes required fields

1. Enter member information:

Email*

Password*

Re-type Password*

Reminder Question*

Answer*

2. Personal Information

First Name*

Middle Name

Last Name*

Date of Birth

Mo* Day* Year*

Marital Status*

Sex*

Street Address*

City*

State*

Zip*

Phone*

3. Insurance Information

Insurance Company*

Insurance Company Address*

Insurance Member ID

Insurance Plan or Group Number

Patient Named Insured?*

Relationship to named insured
First Name of the named insured
Middle Name of the named insured
Last Name of the named insured
Named insured date of birth	Mo: Day: Year:
Marital status of named insured
Sex of named insured
Street Address of named insured
City
State
Zip
Phone

Do you have a secondary insurance policy?*

4. Patient Wellness Information

For the following set of questions, choose the number that best describes your current circumstances on a scale from 1 to 5. 1 being normal to 5 being chronic discomfort.
Appetite*	0 1 2 3 4 5
Balance*	0 1 2 3 4 5
Breathing/Resipiratory*	0 1 2 3 4 5
Concentration/Focus*	0 1 2 3 4 5
Energy Level*	0 1 2 3 4 5
Eye Sight*	0 1 2 3 4 5
Libido*	0 1 2 3 4 5
Muscle Pain*	0 1 2 3 4 5
Pain*	0 1 2 3 4 5
Flexibility*	0 1 2 3 4 5
Sitting*	0 1 2 3 4 5
Skin Condition*	0 1 2 3 4 5
Sleeping*	0 1 2 3 4 5
Standing*	0 1 2 3 4 5
Staying Alert*	0 1 2 3 4 5
Walking*	0 1 2 3 4 5
What is your height?*
What is your weight?*
What was your weight a year ago?*
Do you know your blood pressure now? *	OVER
What are your main medical concerns and complaints?*
What are your long-term health and wellness goals?*
Do you believe you would benefit by having medical devices at home to measure your blood pressure, pulse, weight, breath, heart or lungs?*
When was your last physical check-up?*
Was there a diagnosis?*

Do you use prescription drugs?*

Do you use any alternative medicines?*

You will be prompted via e-mail to complete this questionnaire again in 6 months. Over time, you will have assembled a record of your wellness, which you may then print, and share with your primary physician. Our Privacy Policy protects this information.

5. Doctor Information
Doctor's Last Name
Doctor's First Name
Doctor's NPI Number what's this?
Diagnosis*
Detailed Diagnosis

Coupon Code


You must agree to our terms

If yes, what was the diagnosis and the treatment plan prescribed to you?*
Was there an additional Diagnosis #2 ?*

WELCOME TO YOUR FAMILY DOCTOR AND GENERAL PRACTICE PHYSICIANS We Provide You Medical E-Care,When You Need It and When You Want It.

WELCOME TO YOUR FAMILY DOCTOR AND
GENERAL PRACTICE PHYSICIANS

We Provide You Medical E-Care,
When You Need It and When You Want It.