This form is for general business purposes only.

Please DO NOT include any PHI (Personal Health Information) in this form as it’s not intended nor secure for medical data. Care Convene is a tool for licensed and credentialed providers. We do not employee any providers, so therefore we are unable to provide any medical advice.

We are very happy you have chosen Care Convene but if your medical situation is urgent, please visit a local Urgent Care or Hospital as soon as possible.

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