CBD/THC TELEMEDICINE INTAKE ELIGIBILITY FORM

Patient Contact Information

First Name

Last Name

Date of Birth

Social Security Number

Phone

Gender

Male
Female

*Note: You MUST be located in Texas to qualify for our service.

Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

County You Live In

Guardian Information

If the patient is underage then input all of the guardian's information below.

First Name

Last Name

Last 5 SSN

Date of Birth

Your Current Age

Medical Information

What are your specific symptoms that you would like to see addressed?

Height

Weight

Past Medical Conditions

Daily Medications

Past Surgeries

Any allergies to medications?

Do you or any of your family members have a history of the following?

Check one or more below.

Heart Disease/Stroke
High Blood Pressure
Diabetes
Cancer

Do you feel that there is a lack of quality in your life because of your medical condition?

Choose one below:

Have you been prescribed medical cannabis in the State of Texas before?

Choose one below:

Have you used any illegal substances for recreational use?

Choose one below:

What State is your Driver's License Issued?

Please Upload the Front Side of Your Driver's License

Browse (no files uploaded)

Appointment Details

If you need more information about the qualifying conditions then Dr. McElya will discuss them with you during the telemedicine call.

Referring Provider Name

Please let us know who referred you or enter your referral code:

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. McElya at Neighborhood Medical Center.

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.

Signature

I acknowledge and agree that I have read the Medical Disclaimer above and I am authorizing Dr. McElya to proceed with our telemedicine visit.

Date of Signature

Important:

You may inquire yourself with your insurance company about reimbursement. We do not take insurance at this time.
The consultation fee does not include the cost of the medication prescribed.
Also, if you are experiencing any technical difficulties with our automated processing form above please contact our office directly and one of our Neighborhood Medical Center staff members will assist. Thank you! Phone: 972-726-6464

Billing Address

Address Line 1

Address Line 2

City

Country

Select

State/Province

Select

Zip Code

Sub Total

$150.00

TOTAL

$150.00

Payment Method

Credit Card - Square

CBD/THC TELEMEDICINE INTAKE ELIGIBILITY FORM

Thank you for your telemedicine intake!