The information you provide on this form will be used to register you as a new patient of Dr Irina Strelyuk NMD PLLC via ChARM Electronic Health Records (EHR) System. *

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Consent to use ChARM EHR - Please provide legal information when filling out this form as it will be used to create your patient portal in our electronic health records system called ChARM. For ALL communication between appointments to and from Dr. Irina's office patients are required to utilize the messaging system in their ChARM patient portal. All appointment summaries, appointment changes, lab requisitions, billing, announcements, etc are communicated in this manner, therefore it is crucial that all patients and/or their representatives are willing to learn and use this electronic form of communication. By typing your name below you agree to spend time to familiarize yourself with the ChARM patient portal and agree to use the ChARM patient portal for all communication between appointments. Dr. Irina does not provide tech support. Should you have questions about setting up your patient portal, resetting passwords, etc please contact ChARM directly +1- 855- 571- 5557. *

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Dr. Irina practices via telemedicine only. The patient must be physically located in the state where Dr. Irina is licensed (AZ, CA, ID, WA) at the time of each visit. *

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Name *

First Name

Last Name

Date of Birth *

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If not seeing an email from Dr Irina Strelyuk NMD PLLC labeled “Patient Portal Registration” within 24-48 business hours of submitting this form, I understand that I need to check the spam folder associated with the email address I provided on this form. *

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