New Patient Intake
Texas Telemedicine Doctor
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First name *
Last name *
Date of birth *
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Sex *
Race
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Street address *
City, State, and Zip code
PLEASE PUT YOUR CITY, NOT JUST THE ZIP CODE - Forms that just have the zip code will be rejected
 *
Preferred phone # *
Email address *
How much do you weigh in pounds? *
How tall are you in feet and inches? *
Example: 5 feet 6 inches
Pharmacy name
Pharmacy street address
Pharmacy City, State Zip code
Do you have commercial health insurance or some other type of funding (e.g. Medicare, Medicaid)?
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Allergies - Please list any allergies you have to drugs or other things  (e.g. latex, iodine, peanuts) along with the reaction you experienced. List one allergy per line. Hit [ENTER] for a new line. If you have no known allergies, please answer "None" *
Exampe: Sulfa drugs - rash
Chronic medical problems - Please list your chronic medical problems (e.g. diabetes, hypertension) and the approximate year they were diagnosed. List one problem per line. Hit [ENTER] for a new line.
Example: Diabetes - 2015
Major surgeries/procedures - Please list major surgeries/procedures you have had and the approximate year they occurred. List one problem per line. Hit [ENTER] for a new line.
Example: Coronary artery bypass - 2001
Family medical history (parents and siblings only) - Please list significant family medical problems, the affected family member, and the approximate age they were diagnosed. List one problem per line. Hit [ENTER] for a new line.
Example: Colon cancer - Father - 60 years old
Medications - Please list medications you take including dosage and frequency. List one medication per line. Hit [ENTER] for a new line.
Example: Lisinopril 10 mg once daily
Smoking history - If you smoke or have ever smoked, please list how many packs a day and for how long. If you quit, give the approximate year. If you have never smoked, please answer "Never" *
Example: Smoked 1 pack/day for 20 years. Quit in 2010.
Alcohol consumption *
Other drugs - Do you use any drugs (e.g. marijuana) or nicotine products other than cigarettes (e.g. snuff, vape)? If so, please list which ones and how often. List one drug per line. Hit [ENTER] for a new line.
Example: Smoke marijuana 1 - 2 times a week
Do you have a preferred lab?
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Are there certain labs you would like to have done?
What type of device do you prefer to use for your appointment?
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Please read the email consent form (see link below) and indicate how you would like personal medical information (e.g. labs, questions) communicated with you. *
How did you find Dr. Crump?
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Notice of Privacy Practices - By law, we are required to inform you of your privacy rights. The link below provides this information. Please acknowledge that this information has been made available to you. *
Notice Concerning Complaints - By law, we are required to inform you of the process for filing complaints. The link below provides this information. Please acknowledge that this information has been made available to you. *
Telemedicine consent - By law, we are required to obtain your consent for a telemedicine visit. Please read the document at the link below and then provide us with your consent. If you do not consent, we will not be able to see you. *
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