Legal Name*Enter your legal name just as it appears on your Oklahoma DL or state-issued ID. First Middle Last Your Email* Mobile Phone*For your confidential telemedicine appointment, a camera-enabled smartphone is helpful. However, you may use any pc or tablet with a front-facing camera and microphone.Text Message / SMS Opt-In* I agree to receive text messages for appointment updates and renewal reminders. By checking this box, you agree to receive text message at the mobile number provided above regarding your telemedicine visit and futures renewal reminders. Message frequency may vary. Standard message and data rates may apply. Text HELP for help. Text STOP to cancel.Choose Appointment Day & Time*This field is hidden when viewing the formTelemedicine Appointment Type (HIDDEN DO NOT REMOVE)Telemedicine Appointment: OMMA Evaluation Oklahoma State Issued Photo IDMax. file size: 1 GB.A valid US Passport will also be accepted for proof of identity. An out of state license is not accepted.Physical Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PO Boxes are not accepted as a valid physical address. The OMMA no longer requires doctor's form to match the patient's ID. Date of Birth* (min age: 18) MM slash DD slash YYYY Telemedicine Doctor Consultation* Price: You will submit your payment in the next step through a secure Square checkout. Remember, if for any reason you do not receive a recommendation, we will refund 100% of your consultation fee.Coupon Total $0.00 Credit Card Cardholder Name Card Details Terms of Use* I agree to the Privacy Policy and Terms of Use below. Privacy Policy and Terms of Use
