Phone: (954) 540-2110
Patient Name -- (required)
Name (if different than patient name, i.e. parent or guardian)
Pharmacy Fax #
Select your Telemedicine Kit
COVID-19FluStrepUTIAnemiaBirth ControlErectile Dysfunction
Symptoms Patient is Experiencing
COVID-19/Coronavirus symptomsSore throatFlu-like symptomsFatigueDiscomfort when urinatingErectile Dysfunction symptomsOther/none of the above
I certify that I have read and accept the terms of Physician 360's Informed Consent.
1175 Peachtree St NE,
Atlanta, GA 30361
© 2021 Physician 360 Inc.