Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Dr. Irina practices via telemedicine only. The patient must be physically located in the state where Dr. Irina is licensed (AZ, CA, ID, WA) at the time of each visit. *

I agree to the above

I do NOT agree to the above

Consent to use ChARM EHR - Please provide legal information when filling out this form as it will be used to create your patient portal in our electronic health records system called ChARM. For ALL communication between appointments to and from Dr. Irina's office patients are required to utilize the messaging system in their ChARM patient portal. All appointment summaries, appointment changes, lab requisitions, billing, announcements, etc are communicated in this manner, therefore it is crucial that all patients and/or their representatives are willing to learn and use this electronic form of communication. By typing your name below you agree to spend time to familiarize yourself with the ChARM patient portal and agree to use the ChARM patient portal for all communication between appointments. Dr. Irina does not provide tech support. Should you have questions about setting up your patient portal, resetting passwords, etc please contact ChARM directly +1- 855- 571- 5557. *

I agree to the above

I do NOT agree to the above

If not seeing an email from Dr Irina Strelyuk NMD PLLC labeled “Patient Portal Registration” within 24-48 business hours of submitting this form, I understand that I need to check the spam folder associated with the email address I provided on this form. If you are not seeing a reply after checking the spam folder reach out again and provide a different email address and/or change your email settings to accept emails from info@drstrelyuk.com (all emails and requests are replied to and if you are not receiving a reply that means the email from our end is not being delivered). *

I agree to the above

I do NOT agree to the above