(833) 837-8881
Home
About Us
Medical Solutions
For Physicians
Hospital Administrators & Health Care Executives
Nurses and Repiratory Therapists
The Difference
Next Steps
EBM News
Contact Us
Patient Intake
Clinic Sign-up
Home
About Us
Medical Solutions
For Physicians
Hospital Administrators & Health Care Executives
Nurses and Repiratory Therapists
The Difference
Next Steps
EBM News
Contact Us
Patient Intake
Clinic Sign-up
Patient Intake
Facility/Clinic
(Required)
Patient Number
(Required)
Doctor
(Required)
Name
(Required)
First
Middle
Last
Patient Email
(Required)
Enter Email
Confirm Email
Date of Birth
(Required)
MM slash DD slash YYYY
Consent
Verify that the patient understands the following:
• There may possibly be a copay.
• Patient can cancel RTM services anytime.
• Care Plan may be shared with other providers.
• Only one provider per month can bill for RTM.
• Patient has right to get a copy of Care Plan.
I agree to the privacy policy.
Signature