Mountain Medical Practice

17025 Mount Rose Hwy

Suite C

Reno NV, 89511

(775) 849-3000

Telemedicine & Location
Confirmation Form

Last name, surname, or family name
First name followed by middle name, nickname, or initial
Date of Birth
Example: (555) 555-5555
Example: john@gmail.com
Select Your State
For telemedicine visits, you must be physically located in a state where your provider is licensed at the time of your appointment. Your home address does not matter - only where you are during the visit. The provider holds an active medical license in all states listed as choices above. Select the state where you will be at the time of your virtual visit.
Telemedicine Acknowledgment & Location Confirmation
PATIENT'S ACKNOWLEDGEMENT & CONFIRMATION - By checking the box above, you confirm the following: 1. You have read and understood the Telemedicine & Location Policy and the information in this Telehealth & Location Confirmation Form, 2. You confirm that you are or will be physically located in a state where your provider is licensed to practice medicine at the time of your telemedicine visit, 3. You understand that providing false information may invalidate the visit and could have legal or licensing consequences, 4. By proceeding with a telemedicine appointment, you attest that the location information that you have provided is accurate and truthful.
TeleMedicine & Location Policy
Virtual Visits

Important Practice Update!

Flying duck

Effective June 1, 2026, Mountain Medical Practice will transition to a fully virtual care model with all appointments conducted via secure telemedicine. 

Contact us for additional information and assistance.

(775) 849-3000

Schedule a Virtual Visit