[av_heading tag=’h1′ padding=’10’ heading=’Telemedicine Doctor Request Form’ color=” style=’blockquote modern-quote’ custom_font=” size=’36’ subheading_active=’subheading_below’ subheading_size=’15’ custom_class=”] (for U.S. Residents Only)
[/av_heading] [av_hr class=’invisible’ height=’50’ shadow=’no-shadow’ position=’center’ custom_border=’av-border-thin’ custom_width=’50px’ custom_border_color=” custom_margin_top=’30px’ custom_margin_bottom=’30px’ icon_select=’yes’ custom_icon_color=” icon=’ue808′ font=’entypo-fontello’] [av_textblock size=” font_color=” color=”]

To have a telemedicine doctor contact you, just fill out the form below with your availability and click “Submit”.

[/av_textblock] [av_contact email=’telemedicine@l-nutra.com, ana@l-nutra.com’ title=” button=’Submit’ on_send=” sent=’Thank You. Your message has been sent!’ link=’manually,http://’ subject=’Telemedicine Doctor Request’ autorespond=” captcha=” form_align=” color=”] [av_contact_field label=’First name’ type=’text’ options=” check=’is_empty’ width=’element_half’ multi_select=”][/av_contact_field] [av_contact_field label=’Last name’ type=’text’ options=” check=’is_empty’ width=’element_half’ multi_select=”][/av_contact_field] [av_contact_field label=’E-Mail’ type=’text’ options=” check=’is_email’ width=’element_half’ multi_select=”][/av_contact_field] [av_contact_field label=’State’ type=’select’ options=’Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming’ check=” width=’element_half’ multi_select=”][/av_contact_field] [av_contact_field label=’Phone Number’ type=’text’ options=” check=’is_phone’ width=’element_half’ multi_select=”][/av_contact_field] [av_contact_field label=’Best Days of the Week/Hours for Doctor Call’ type=’text’ options=” check=’is_empty’ width=’element_half’ multi_select=”][/av_contact_field] [/av_contact]