Registration For School Telehealth Services

Please select your student's school.

--All Saints (Norwalk, CT)Assumption Catholic School (Fairfield, CT)Cardinal Kung Academy (Stamford, CT)Catholic Academy of Bridgeport-St. Andrew (Bridgeport, CT)Catholic Academy of Bridgeport-St. Ann (Bridgeport, CT)Catholic Academy of Bridgeport-St. Augustine (Bridgeport, CT)Catholic Academy of Bridgeport-St. Raphael (Bridgeport, CT)Greenwich Catholic (Greenwich, CT)Holy Trinity Catholic Academy (Shelton, CT)Immaculate High School (Danbury, CT)Kolbe Cathedral High School (Bridgeport, CT)Malta House (Norwalk, CT)Notre Dame High School (Fairfield, CT)Our Lady of Fatima (Wilton, CT)Our Lady of Grace Preschool (Stamford, CT)Regina Pacis Academy (Norwalk, CT)St. Aloysius (New Canaan, CT)St. Catherine of Siena (Trumbull, CT)St. Gregory the Great (Danbury, CT)St. James (Stratford, CT)St. Joseph High School (Trumbull, CT)St. Joseph-DANBURY (Danbury, CT)St. Mark (Stratford, CT)St. Mary-BETHEL (Bethel, CT)St. Mary-RIDGEFIELD (Ridgefield, CT)St. Peter (Danbury, CT)St. Rose of Lima (Newtown, CT)St. Theresa (Trumbull, CT)St. Thomas Aquinas (Fairfield, CT)The Catholic Academy of Stamford (Stamford, CT) Please select your school.

You can add additional students later in the registration process.

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Your student's birthday is only used to help your doctor keep proper medical records.

JanFeb MarApr MayJun JulAug SepOct NovDec 010203 040506 070809 101112 131415 161718 192021 222324 252627 282930 31 202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933 Please select a valid birthday.

Your student's gender is only used to help your doctor keep proper medical records.

--select-- Male Female Unspecified Please make a selection.

We require a parent or legal guardian to be present during telehealth consultations with your student.

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Your email is kept confidential and only used for matters relating to your student's care.

A valid email address is required.

We use these number(s) to invite you to your student's telehealth consultation. Only the first number is required.

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We are required to have a mailing address for your student's health record.

Please enter your valid 5 digit Zip Code.

We are required to have a mailing address for your student's health record.

This field is required.

We will use the same contact and insurance information for all your students.

Yes No

Uploading a photo of your insurance card allows us to bill your insurance. Smartphone users can take the photos with their phone by clicking the buttons below. Desktop or Laptop users should first use their webcam, digital camera, or smartphone to take the photos and save them to your computer. Then come back and use the buttons below to select your photos.

Insurance Card Front: choose a file cancel this picture Please upload a picture of your card's front side. Insurance Card Back: choose a file cancel this picture Please upload a picture of your card's back side.

I do not have insurance nor participate in a health share. I undertand I will be billed directly and have reviewed the payment options on this website. You must agree to the terms of use.