Virtual Visit Help Request

To better help you, we need a little information about your device and the questions you have for us. Please fill out the form below, and we will call you back.

You can also call us directly at 1-800-ROSWELL (1-800-767-9355).

Fields marked with an asterisk * are required.

Your Information

About You

First name *

Last name *

Are you calling for yourself, or on behalf of someone else? * For myself For someone else

Patient MRN *

Date of birth * (mm/dd/yyyy)

Your Patient's Phone number * (###-###-####)

About The Patient

Patient's first name *

Patient's last name *

Patient's date of birth *

Your relationship to the patient *

Your Phone Number * (###-###-####)

Your Patient's Request

I need... * Technology support A question answered about my virtual visit

Technology Support

Please tell us about the device you are using * Desktop/Laptop Computer Tablet/iPad Smartphone Other Phone

Type of Computer * Mac/Apple Windows

Type of Smartphone * iOS/Apple Android/Google

Internet Browser you're using * Chrome

Safari

Mozilla Firefox

Internet Explorer

Other

What other browser are you using? *

Please describe the technology problem you are experiencing: * Select all that apply. Difficulty downloading WebEx app Cannot get video to work Cannot get audio to work Privacy concerns No camera-enabled device Poor or no internet connection Other

What other technology problem are you having? *

Questions about Virtual Visits * I've connected, but no one from Roswell has joined by virtual visit Other

What other questions do you have about your virtual visit? *

Your Information
Your Request
Finish

Your Patient's Residential Address

Your Information

About You

About The Patient

Your Patient's Request

Technology Support