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Forms

Thank you for taking a few minutes to fill out the forms for your appointment. Completing the forms helps me to prepare for your appointment and make it more efficient. Also, if you have an issue that I feel may be more appropriate for another setting, I can let you know before your appointment, and it may save you some time and money.
New patient instructions
  1. Complete the "New patient form"
  2. Look under "Issues," and complete a form for each issue you would like to address. If you do not see your issue listed, please complete the "Other issue (form not found)" form. If you have more than one issue that is not listed, you can put them all on one "Other issue" form.
  3. If you have medical records you would like me to have, you can fax them to 506-700-6425. If you would like to email them to me, send an email without the records to contact@texastelemedicinedoctor.com stating that you want to send me records. I will instruct you on what to do next. This way we can ensure that the connection is secure. If you would like me to request your records from another doctor/hospital/other, please fill out a separate medical release form for each entity (medical release form). After you print it and sign it, you can email or fax it back to me.
Established patient instructions
  1. If any of your personal information (e.g. phone, address, email) has changed since I last saw you, please complete the "Established patient personal information change" form.
  2. If you have had any significant changes in your medical history (e.g. diagnoses, medications, allergies, family history), please complete the "Established patient medical information change" form. If you would like me to request records from another doctor/hospital/other, please fill out a separate medical release form for each entity (medical release form). After you print it and sign it, you can email or fax it back to me.
  3. Under "Issues," please complete a form for each issue you would like to address. If you do not see your issue listed, please complete the "Other issue (form not found)" form. If you have more than one issue that is not listed, you can put them all on one "Other issue" form.

Personal information / Medical history
New patient form
Established patient personal information change
Established patient medical information change

Medical release
Medical release form

Issues
Allergies
Anxiety
Asthma
Back pain
Birth control
Cough
Crohn's disease
Depression
Diabetes, type 1
Diabetes, type 2
Eczema (atopic dermatitis)
Erectile dysfunction (ED)
Eye redness / discharge
Fever blister / Cold sore
Gout
Herpes, genital
High cholesterol
Hypertension (high blood pressure)
Hypothyroidism (low thyroid)
Insomnia
Menopause (hormone replacement therapy)
Migraine headache
Neck pain
Other issue (form not found)
Overweight / Obesity / Desire to lose weight
Psoriasis
Psoriatic arthritis
Poison ivy / Contact dermatitis
Rash
Sinus congestion / Sinusitis
Sore throat
STD screening / infection (female)
STD screening / infection (male)
Urinary tract infection / UTI (female)