TeleHealth Registration

Fill out this simple form before you travel to make sure you have the peace of mind that comes from prompt access to a medical professional while you are away from home.

Name

First Name

Last Name

Email

Cell Phone

(###)

###

####

Where are you going?

List the cities you will be visiting

Date of Departure

Date of your first leg of travel

MM

DD

YYYY

Departure Flight Number

Flight number of the first leg of your trip (include letters and numbers)

Date of Return

If unsure, just give us your best guess

MM

DD

YYYY

Return Flight Number

Flight number of the first leg of your return trip (include letters and numbers)

Name of Primary Physician

Physician Phone

(###)

###

####

Concerns

List any health concerns you may have as you prepare to travel

By clicking 'Submit', you give permission for Gold Cross to transfer the information in this form to Centred-Wellness, tele-medicine provider. Your information will be used solely for the purpose of providing remote tele-health assistance and will not be sold to any third party entities.