Get Started — TerryHealth LLC

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Patient Screening Form

This form helps us confirm you qualify for TerryHealth services. We serve Florida residents without active health insurance. All information is kept strictly confidential.

ℹ️ Your first consultation is free. If you decide to become a TerryHealth patient, a one-time New Patient Evaluation ($100) will be scheduled before your ongoing care begins.

📍 TerryHealth serves patients physically located in Florida who do not have active health insurance. If you have active health insurance, we are unable to provide services at this time.

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Application Received!

Thank you for reaching out to TerryHealth. We will review your information and contact you within 24 hours at the email and phone number you provided.

If you qualify, we will send you a patient portal invitation to schedule your free first consultation with Teresa Vazquez, FNP-BC.

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Personal Information

First Name *

Last Name *

Date of Birth *

Gender

Contact Information

Email Address *

Phone Number *

Preferred Language

City *

Zip Code *

Eligibility Questions

Are you currently located in Florida? *

Do you currently have health insurance? *

Main reason for seeking care *

Do you have any existing medical conditions?

Current medications (if any)

Membership Interest

Which option interests you?

How did you hear about TerryHealth?

I consent to receive SMS text messages from TerryHealth LLC regarding my care, appointments, and billing. Message & data rates may apply. Reply STOP to opt out. See Privacy Policy.

I have read and agree to the Terms of Service and Privacy Policy. I confirm I am a Florida resident without active health insurance.

We will review your application and respond within 24 hours. Your information is secure and confidential.

Get Started with TerryHealth

Fill This Form

We Review

Free Visit

Patient Screening Form

Application Received!