Request a wiseMIND Consultation
This form helps prospective patients and our psychiatrists connect more efficiently and explore whether the requested relationship will be a good fit. This form helps ensure you find the right psychiatrist for your needs.

Once reviewed, you will be contacted by our office via phone (210-236-5108).

Sign in to Google to save your progress. Learn more
Email *
Contacting Dr. Milmo or Dr. Chatrath does not establish a professional physician-patient relationship. If you are or believe you are experiencing a medical or psychiatric emergency, including suicidal or homicidal thinking, side effects to medication, or any other urgent or time-sensitive matter in which you need an immediate response, do not use this service. Instead call 911, 988, or go to your closest emergency department.
*
Required
Please keep in mind our practice is not able to meet requests for legal or disability purposes. *
Required
Do you have a preference on which psychiatrist you would like to see? This is subject to their availability.
*
First and last name: *
Gender:
*
Date of birth:
*
MM
/
DD
/
YYYY
Best contact phone number:
*
My relationship to the patient:
*
How did you hear about us?
*
I understand I am responsible for payment in full at the time service is rendered. I will be provided a superbill statement so I may try to get some reimbursement from my insurance company if I am eligible. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of wiseMIND. Report Abuse