Refill Prescription Intake Form

Medical Disclaimer 

Requests for e-visits and/or online prescription refills must be confirmed and scheduled by our office prior to the e-visit and/or online prescription refills. Prior to the visit please fill out our medical questionnaire. After reviewing your information, or during the e-visit it may be determined that your problem is too complex for an e-visit session. In that case, our office will schedule you for a traditional office visit and your e-visit fee will be applied to the patient balance related to your office visit. Our physician appropriately documents the virtual e-visit, including all pertinent communication related to the encounter, in the patient’s medical/health record. The physician has a defined period of time within which responses to a virtual e-visit request are completed. During the virtual e-visit, the physician may make recommendations, provide medical advice, and/or prescribe, refill or recommend medications. The physician may suggest the patient receive additional care, examination, testing, and/or treatment at a medical facility in person. If necessary, the physician may also suggest that the patient receive care in an emergency room. Communication during an e-visit may be exchanged via teleconference, landline phone, cellular phone, and online chat per the State of Texas. By requesting an e-visit you acknowledge that personal health information will be communicated. A virtual e-visit may include the total interchange of online inquiries and other communications associated with this single patient encounter, subject to the determination of the physician. As with any medical service, decision, or treatment, there are risks; and, an e-visit is no different. Because this visit is electronic and not in person, you acknowledge that the risk may be greater than a traditional office visit, and by requesting the visit you agree to accept the outcome-even if it is undesirable. Also, in the event that you cancel your telemedicine appointment, please be aware that a 3% processing fee will apply should a refund be requested. In addition, you agree to abide by our office's routine policies including any policy related to litigation.  I acknowledge I am paying for a prescription refill via online with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.