Telehealth Appointment Request
County
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Lander
Humboldt
White Pine
Eureka
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Inmate first/last Name
Inmate DOB MM/DD/YYYY
Last 4 of inmate SS number
Facility Address
Facility Contact Phone Number
Facility Contact E-mail
Person of Contact Name *if multiple, please include all*
Pharmacy Address (If applicable)
Appointment description/Other notes for the provider
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