Telehealth Support Subscription Form Morning Star RSA

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What We Offer
Who We Are
Contact Us

For Inquiries, Please Call:

240-770-7774

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Telehealth Support Service Sign Up Form

Welcome to our Telehealth Support Service! Please complete the form below to begin your monthly subscription for virtual healthcare consultations. Our team of healthcare professionals is here to provide you with personalized care via video calls, including regular check-ins, dietary consultations, and health education tailored to your needs.

Personal Information

Please fill in the following fields

First Name *

Last Name *

Gender *MaleFemaleNon-BinaryPrefer not to say

Phone Number *

Email Address *

Date Of Birth

Address for In-Home Assessments

Street Address *

(Optional) Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Emergency Contact Phone Number *In case of urgent health concerns

Emergency Contact Name

What's your relationship with the Emergency Contact?

Health Information

Do you have any current medical conditions?YesNo(e.g., diabetes, hypertension, heart disease, etc.)

If Yes, Please specify

Are you currently on any prescription medications?YesNo

If Yes, Please list them below

Do you have any allergies or sensitivities?YesNo

If Yes, Please list them below

Do you currently see a doctor or health specialist? *YesNo

If yes, please provide details or name of physician

Have you had a recent health check-up? *YesNo

If Yes, when was your last check-up?

Telehealth Service Plan Plan Details

Preferred Frequency of Consultations:WeeklyBi-WeeklyMonthlyOther

Your preferred frequency of Consultations?

Preferred Time of Day for Consultations:Morning (8 AM – 12 PM)Afternoon (12 PM – 4 PM)Evening (4 PM – 8 PM)Flexible

Type of Consultations Requested (Select all that apply):General Health Check-ins.Dietary Consultation (meal planning, nutrition advice).Health Education (chronic disease management, fitness, etc.).Mental Health Support (stress management, coping strategies).Other:

Other:

Do you have access to a device with a camera and microphone for video calls?YesNo

Preferred Platform for Video Calls (Select all that apply):ZoomGoogle MeetSkypeOther:

Other Platform of Choice for Video Calls:

Payment Information

By signing up for the Monthly Wellness Package, I agree to the terms of service, including the subscription model, health assessments, and coaching services. *I agree to the Terms & Conditions.I understand that this is a subscription-based service, and I can cancel at any time with appropriate notice.

I consent to having bi-weekly health assessments conducted by a registered nurse at my home, and I understand that my health data may be stored and used for ongoing wellness coaching and monitoring purposes. *I consent to the Health Monitoring Terms.

Morning Star Residential Agency delivers compassionate, personalized in-home care tailored to each individual’s needs.

8855 Anapolis Rd., Suite 305
Lanham, MD 20706
240-770-7774
dominionacademy@hotmail.com

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