Start Your Online Visit
Fill out the intake below to start a request through our Pharmacy Hub. A licensed clinician reviews every submission and reaches out the same day — no waiting room, no phone tag.
Complete the form below with your symptoms, current medications, and contact details.
A licensed clinician reviews your case and follows up by phone or secure message if needed.
You hear back the same day — approved prescriptions ship or send to your pharmacy.
Patient Intake Form
Your intake is reviewed on a HIPAA-compliant platform, the same privacy standard as your in-office chart. This form is not monitored for emergencies — if you are experiencing a medical emergency, call 911 or go to the nearest emergency room.
Frequently Asked Questions
How long does the intake take?
Most patients finish in under five minutes. The form only asks for what a clinician actually needs to review your request.
What happens right after I submit?
A licensed clinician reviews your intake the same day. If anything needs clarifying, they’ll reach out by phone or secure message before making a decision.
Is my information kept private?
Yes. Submissions go through a HIPAA-compliant system and are reviewed only by the clinician handling your case.
Do I need to be an existing patient?
No. New patients can complete this same form. Existing patients may simply move through review faster since basic details are already on file.
What if my case needs an in-person visit?
Your clinician will tell you directly and help you get scheduled in the office. Nothing about submitting this form locks you into an online-only path.
Piedmont Colorectal Associates · 35 Collier Road NW, Suite 475, Atlanta, GA 30309 · Office phone: (404) 351-7900
Medical Disclaimer
This form is for general prescription requests only and does not replace an in-person medical evaluation. It is not monitored for emergencies. A licensed clinician makes the final decision on every request, and may recommend an in-person visit at any point in the process.