Scarlet Plus - Secure Forms

Your full legal name:

Please enter your full name.

Date of birth:

Please select your Birthday.

Email address where we can reach you

Please enter a valid email address.

Mobile number

City:

Please add city name.

State:

Please add state name.

Zip Code:

Please add Zip Code.

Appointment Type:
Any In-Person Telehealth

Type of Visit:

Please select reason for appointment.

Please select your available times:

Self Pay Insurance Card

Upload a Copy Enter Manually

Insurance Card Front

Click to upload

Please upload the front of your insurance card.

Insurance Card Back

Click to upload

Please upload the back of your insurance card.

When taking a photo, make sure the card...

Is lying flat and centered in the camera view.

Is well lit with minimal glare on the surface.