Patient Online
Consult Form

See a physician without leaving home. Complete the form below and a doctor will consult with you within 2–3 hours. Any prescription will be sent to your nearest pharmacy within 1 hour of your consultation.

💬 Response within 2–3 hrs 💊 Rx in 1 hr 💳 $89 flat fee 🚫 No pain medications

⚠️ This service is for non-emergency consultations only. We do not prescribe pain medications. For life-threatening emergencies please call 911 immediately.

Patient Info

Contact & Referral

Medical History

Files & Submit

📝

Describe Your Symptoms

Patient Online Consult Form:

"Describe how you are feeling, e.g. I have a sore throat for x many days or my ear aches or it hurts when I urinate or I have a cut etc... at the end of this form, please attach pictures of the areas you would like us to assess. If you need a medication refills, write the name of the medication as it shows in the original medication order e.g. Keflex 500 mg po qid #40 etc.. and attach a picture of the old rx. We donot provide pain medications.."*

Full Name:*

First NameLast Name

FULL ADDRESS*

Street Address

CityState

Postal

CELL PHONE:*
Please enter a valid phone number.

EMAIL:*
example@example.com

DOB:*

MonthDayYear

PHARMACY NAME:

PHARMACY NUMBER:

EMPLOYER:

HOW LONG EMPLOYED THERE:

FAMILY DOCTOR NAME:

PERSON TO CONTACT IN CASE OF AN EMERGENCY:

Name:

First NameLast Name

Relationship:

Phone:
Please enter a valid phone number.

REFERRED BY:

Newspaper:(name)

Magazine:(name)

Friend/Family:(name)

Other:

Medical History

Date of Last Blood Work (i.e. during physical, surgery, traveling, etc.) :

MonthDayYear

Do you have Kaiser Insurance?*

YesNo

Do you have any allergies( penicillin, eggs, shellfish, metals, iodine, etc)?*

YesNo

If yes, please list:

Are you currently taking medications?*

YesNo

If yes, please list:

Do you have a bleeding disorder?*

YesNo

Do u have menstrual cycles that are heavy and last more than seven days?*

YesNo

Do you have a history of poor healing? (ie. Keloids, diabetes, etc)*

YesNo

Are you pregnant?*

YesNo

How many children do you have?*

If you had children, did you have any through c-section?*

YesNo

Have you had a hysterectomy?*

YesNo

If Yes, Date?

MonthDayYear

Have you had your gall bladder removed?*

YesNo

Have you had your appendix removed?*

YesNo

Have you had weight loss surgery?*

YesNo

If yes,Which kind?

Have you ever had Bell’s Palsy?*

YesNo

Do you smoke?*

YesNo

If yes, how often and how much:

Have you ever had any problems with general anesthesia?*

YesNo

Have you ever had any problems with local anesthesia?*

YesNo

Have you had any previous surgery?*

YesNo

Describe type of surgery and date of year of surgery

Do you drink alcohol?*

YesNo

If yes, how often and how much:

Have you ever had a history of facial numbness or weakness?*

YesNo

Have you ever had a cold sore?*

YesNo

Have you ever had a herpes out-break?*

YesNo

If yes, how often?

Have you ever had an AIDS test?*

YesNo

What was the result?

Do you have high blood pressure?*

YesNo

Do you have varicose veins?*

YesNo

Have you recently had a weight loss or gain (over 10 lbs)?*

YesNo

Your current estimated weight (in lbs)*

Your height ( in feet )*

Have you ever had hepatitis or jaundice?*

YesNo

Do you have any eye problems?*

YesNo

If yes, please list:

Has any member of your family ever had a problem with local or general anesthesia?*

YesNo

Is there any medical condition that you have that I should know about?*

YesNo

If yes, please list:

Have you experienced a recent emotional crisis?*

YesNo

Explain: In the last two years, how many times have you been to emergency room?*

You give us permission to talk to your doctor about your care at Vita Surgical Group.*

YesNo

Upload 360(take pictures from different angles) images of the areas you want to be consulted on.

Cancelof

Upload any recent labs within 12 months.

Cancelof

ALL DISPUTES BETWEEN YOU AND US WILL BE SUBJECT TO INDIVIDUAL ARBITRATION ACCORDING TO THE FAA.*

Yes

Should be Empty:

Prefer to call?

For same-day urgent care or to speak with our team directly, calling is the fastest option.

(703)-471-4253

Mon – Fri 8 am – 5 pm · Sat 8:30 am – 1 pm

Schedule In-Person Visit

💬 How It Works

Complete this formDescribe your symptoms and upload any relevant photos or lab results.

Physician reviewA doctor reviews your submission and consults with you within 2–3 hours.

Prescription sentIf medication is required, it is called in to your chosen pharmacy within 1 hour of consultation.

Pay $89Flat consultation fee. No hidden charges. We do not prescribe pain medications.

🕐 Clinic Hours

Mon – Fri8:00 am – 5:00 pm

Saturday8:30 am – 1:00 pm

SundayClosed

📍 Our Location

🏢

Address3543 West Braddock Road, Suite 400D, Alexandria, Virginia 22302 — near the intersection of King St and W. Braddock Rd., behind the Bradlee Shopping Center.

📞

Phone(703)-471-4253

💳

Consult Fee$89 flat fee

About Our Practice

Dedicated to your community

At Ridge and Valley Health we are dedicated to serving the community through personalized and timely medical visits. We do this by limiting the number of patients we schedule each day and making sure our doctors are accessible for urgent care appointments and follow-up needs.

Schedule an In-Person Visit

📍 Location

Alexandria Clinic

3543 West Braddock Road, Suite 400D, Alexandria, Virginia 22302 — near the intersection of King St and W. Braddock Rd., behind the Bradlee Shopping Center.
Phone Number: 703-471-4253
Text Us at: 202-452-1332

📞 Contact(703)-471-4253
Call first for urgent care availability

🕐 HoursMon – Fri: 8:00 am – 5:00 pm
Saturday: 8:30 am – 1:00 pm

Patient OnlineConsult Form

Describe Your Symptoms