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Patient Date of Birth:
New or Exisiting Patient?	New Patient Existing Patient
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Preferred Contact Method:	Home Phone Cell Phone
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Appointment Information

Appointment Type:	WellSickTelemedicine
Preferred Provider:	No PreferenceRaymond Tidman, MDLee Tidman, FNP-C
Preferred Location:	Blue Ridge, GA
Preferred Day:	Monday Tuesday Wednesday Thursday Friday
Preferred Time:	Morning (AM) Afternoon (PM)
Secondary Preferred Day:	Monday Tuesday Wednesday Thursday Friday
Secondary Preferred Time:	Morning (AM) Afternoon (PM)
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