Telemedicine Visit

Your Visit Information

You've been referred for a virtual visit with a Clover-affiliated physician. Please review the documents below, then complete this short form so we can text you about your visit.

I have read and agree to the Telemedicine Informed Consent and the Privacy Policy. By checking this box and providing my phone number, I consent to receive automated text messages from Clover Health and its partners (including Beluga Health) about my telemedicine visit — including appointment reminders, follow-up messages, and prescription information. Message and data rates may apply. Message frequency varies. Reply STOP to opt out, or HELP for help.

First name *

Last name *

Date of birth *

MM / DD / YYYY

Clover Member ID *

On the front of your Clover card

Mobile phone *

We'll text you a 6-digit code to confirm.

Anything you'd like the doctor to know? (optional)

Questions? Call Clover Member Services at 1-888-778-1478 (TTY 711), 8 am–8 pm local time, 7 days a week.*

Your Visit Information

Confirm your visit