New Patient Intake — MyTelePep

Step 1 of 4

Your Identity & Contact

We collect only what your Florida-licensed provider needs to verify your identity and contact you about your visit.

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HIPAA Minimum Necessary Standard: We only collect fields required to create your patient record in eClinicalWorks and conduct your telehealth consultation. No SSN, no insurance, no unnecessary demographics.

🛡 Minimum Necessary Fields Only

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Florida Residency Required. You must be a Florida resident and physically located in Florida at the time of your consultation. By continuing you confirm this.

Legal First Name * First name is required

Legal Last Name * Last name is required

Date of Birth * Must be 18 or older Valid date of birth required (must be 18+)

Biological Sex * Required for clinical prescribing Please select biological sex

Email Address * Visit link and prescription notifications sent here Valid email address required

Mobile Phone * Provider may contact you here Valid phone number required

State of Residence * MyTelePep serves Florida residents only You must be a Florida resident to use MyTelePep

🔒 Encrypted · HIPAA-Compliant · Not sold or shared

Step 2 of 4

Health Profile

Your provider needs this to evaluate you safely and avoid dangerous drug interactions. Only essential clinical information is collected.

🛡 Clinical Minimum Only — No Unnecessary History

Current Medications *

Type a medication and press Enter or comma to add. Click "None" if you take no medications.

✓ None / No Medications

Required for drug interaction safety review before any prescription

Known Allergies *

Type an allergy and press Enter or comma to add. Click "None" if you have no known allergies.

✓ No Known Allergies (NKDA)

Required before any prescription can be written

Health Goals & Chief Concern * Helps your provider tailor the consultation to your needs Please describe your health goals

Relevant Medical History (Optional) Leave blank if none relevant — this is optional

🔒 Encrypted · HIPAA-Compliant · Not sold or shared

Step 3 of 4

Telehealth Consent & Signature

Required by Florida Statute §456.47. Please read and acknowledge each item, then sign below.

Electronic Signature * Draw your signature below using mouse or touch

Sign Here Clear Signature

Signature is required

Full Name (Typed) * Please type your full name

Date Signed

🔒 Encrypted · HIPAA-Compliant · Consent recorded with timestamp

Step 4 of 4

Review & Submit

Review the information below. When you submit, your record will be created in our eClinicalWorks EHR and you'll be ready to book your consultation.

Identity & Contact Edit

Full Name—

Date of Birth—

Biological Sex—

Email—

Phone—

State—

Health Profile Edit

Medications—

Allergies—

Health Goals—

Medical History—

Consent & Signature Edit

Consent Items

Signed By—

Date Signed—

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eClinicalWorks Integration: On submit, a FHIR R4 Patient resource will be created in your eClinicalWorks account using only the minimum necessary fields above. Your patient ID will be returned and displayed for confirmation.

🔒 Encrypted · HIPAA-Compliant · Minimum Necessary Fields Transmitted

Creating your patient record in eClinicalWorks...

✓ Record Created Successfully

Your patient record has been created in eClinicalWorks. The FHIR R4 payload below shows exactly what minimum necessary data was transmitted.

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Patient Record Created in eClinicalWorks

Your intake is complete. A confirmation has been sent to your email address. Your provider will contact you within 1 business day to schedule your telehealth consultation.

eCW Patient ID: Loading...

FHIR R4 Patient Resource — Minimum Necessary Fields Transmitted

This JSON payload represents the FHIR R4 Patient resource transmitted to eClinicalWorks via the POST /fhir/r4/{practice_code}/Patient endpoint. In production, replace the demo endpoint with your live eCW practice code and OAuth 2.0 bearer token. Your eCW admin must enable FHIR API access at fhir.eclinicalworks.com and provide your client_id and client_secret to Shane for the production integration.

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