Telemedicine

Please complete the following Telemedicine Form

Section 1:  Patient Demographic Information

as it appears on your health card

as it appears on your health card

If you are not a current patient with Acton Medical continue answering the rest of section 1; current patients can move onto section 2.

Are you currently suffering from a medical condition, illness, or injury?
Have you been hospitalized in the last 12 months?

Thanks for submitting!