Telemedicine Intake Form for Emergency Kit

Please fill out our questionnaire below. We do kindly ask that all information is correct including pharmacy numbers and fax numbers so that your prescription is not delayed. Thank you!

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Medical Disclaimer 
NEVER REQUEST AN ELECTRONIC VISIT FOR AN URGENT MEDICAL PROBLEM, CALL 911 INSTEAD.
Patient agrees to virtual e-visit service terms, privacy policy, and charge for receiving a virtual visit from Dr. Gregory Burzynski at Houston Concierge Medicine. 
Requests for e-visits must be confirmed and scheduled by our office prior to the e-visit. 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 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. 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 telemedicine consult with the physician and the outcome will be based solely on the physician's medical discretion and the fee is non-refundable.

Important:

  • If you are experiencing any technical difficulties with our automated processing form above please contact our office directly and one of our Houston Concierge Team members will assist. Thank you! Phone: 713-333-6464
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Sub Total
$345.00
TOTAL
$345.00

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Thank you for contacting us!

Thank you for reaching out to Houston Concierge Medicine. We appreciate your interest in our services and for taking the time to fill out our forms.

You can schedule your appointment HERE.

We look forward to serving you and providing you with exceptional healthcare services.

Warm regards,

Houston Concierge Medicine Team

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