Let your doctor know that you are interested in Online Consultation now

Many people want to use a secure and confidential e-mail service to communicate with their own doctor. In fact, a recent survey shows that almost 40% of patients would pay for this access and would change doctors to be able send secure e-mail to their own doctor. Until now, most physicians were concerned about using regular e-mail because it is like sending a post card through the mail... anyone can read it.

Now there is a way to communicate with your doctor using a secure and confidential e-mail system called Online Consultation™ offered by Medem.

Online Consultation and the modest associated fee, is designed not only for your convenience, but also to save you money when your questions, that previously required an office visit, can be adequately answered online.

Why use Online Consultation?

Online Consultation is fast and easy

While most appointments require you and your physician to be in the same room, there are many instances where you can be provided with as much, or more, individualized information without a face-to-face meeting. Some specific examples include:

• Advice on changes in your particular medical situation
• Gathering information on options for treatment
• Interpretation of abnormal test results with suggestions for further evaluation or therapy

We know that coming in for an office visit is not always convenient and has a real cost to you as a patient. Co-payments, gas and parking, lost wages, child-care and other "hard-dollar" costs for office visits add up.

Your doctor will receive information from us indicating that one of his/her patients (you remain anonymous) is interested in this type of service.

ENTER YOUR PHYSICIAN'S CONTACT INFORMATION
Physician First Name*:
Physician Last Name*:
Physician E-mail Address*:
Physician Phone Number*:	ext
	suggestion: (415)555-1212 ext 555 (where applicable)
Physician Address 1*:
Physician Address 2*:
Physician City*:
Physician State*:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AS FM GU MH MP PW PR VI AE AP AA
Physician Zip Code*:
Physician Specialty*:	Other Addiction Medicine Allergy/Immunology Allied Health Anesthesia Cardiology Clinical Endocrinology Colon and Rectal Surgery Dermatology Emergency Medicine Endocrinology Facial Plastic Surgery Family Practice Hand Surgery Internal Medicine Medical Genetics Nephrology Neurological Surgery Neurology Nuclear Medicine Obstetrics and Gynecology Occupational Medicine Oncology Ophthalmology Orthopedics Otolaryngology Pain Management Pathology Pediatrics Physical Medicine and Rehabilitation Plastic Surgery Preventive Medicine Psychiatry Radiology Surgery Thoracic Surgery Urology
Your Health Plan*:
* indicates a required field to be filled out.

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