Submission Widget Builder

Configure final review and submission settings

Content Settings

Customize the submission widget text and messaging

Widget Title

Description

Submit Button Text

Consent Text

Live Preview

See how your submission widget will look

Review & Submit

Please review your information before submitting your consultation

Patient Information

Name: John Doe

Email: john.doe@example.com

Phone: (555) 123-4567

Medical Questionnaire

10 of 10 questions answered

Uploaded Documents

lab_results.pdf

id_verification.jpg

Selected Pharmacy

CVS Pharmacy

123 Main Street, Springfield, IL 62701

Selected Package

Premium Plan$499

I agree to the Terms of Service and Privacy Policy

I consent to telehealth services and understand that a licensed healthcare provider will review my information. I acknowledge that treatment may not be appropriate for everyone and that I may be denied treatment based on the provider's medical judgment.

By submitting this exam, you authorize us to share your medical information with licensed healthcare providers for the purpose of evaluation and treatment. Your information is protected under HIPAA regulations.