Schedule a POLST Appointment with us

In order to help schedule a POLST appointment, please provide the following information:

Telemedicine visits to complete a POLST form generally take anywhere from 15 minutes to one hour, when is the best time for an appointment? Please check all that apply.

Please note that we require the following information for whom the POLST form is being completed:


Full Name and Date of Birth


Medicare Number


If you are completing a POLST form on behalf of another person, please note this may only be done if that person lacks the ability to make their own decisions and that you are the next of kin or appointed health decision maker. 


Looking forward to meeting you online!

Thanks for submitting. We will get back to you in order to confirm an appointment time as soon as possible.