SILVA PSYCHIATRIC CARE
MEET DR. SILVA
NEW PATIENTS
COST OF TREATMENT
Patient Reviews
REQUEST AN APPOINTMENT
ADULT ADD/ADHD?
Frequency of Visits
Frequently Asked Questions
THE CONCIERGE MODEL
WHAT IT IS
Concierge Reviews
TELEMEDICINE
WHAT IT IS
HOW IT WORKS
PATIENT REVIEWS
TREATMENT PHILOSOPHY
INFORMATION FOR PATIENTS & THEIR FAMILIES
ARCHIVES
CONTACT
ABOUT
PAYMENTS
REFILL POLICY
CANCEL/NO-SHOW
PRIVACY
FORMS
RECOMMENDED
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Mr.
Mrs.
Ms.
Dr.
Patient Name
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Last
If you are not the patient, please explain in the comments section below.
preferred telephone:
Area Code:
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Address (TEXAS only)
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State
Zip Code
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Date of Birth
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Age
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E-mail
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Please Confirm:
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Dr. Silva may use this e-mail address to notify me of appointments.
ENTER PHARMACY NAME,
and
STREET
ADDRESS.
All prescriptions are sent electronically
(NO INSURANCE? grocery stores are less expensive!)
PREFERRED PHARMACY
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State
Zip Code
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USE STREET ADDRESS. TEXAS OR MAIL-ORDER ONLY.
Select One Payment Method:
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ZELLE Online Payments
Credit or Debit Card
Select only one option. To sign up for Zelle, please visit the Payments page under the ABOUT tab in the main menu above.
How Did You Hear About Silva Psychiatric Care?
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Google Search
OTHER Internet Search Engine
Friend / Word of Mouth
Referred by Physician (please specify below:)
I Am a Former Patient
Referred by Caseworker, Therapist (please specify)
Other (please specify below:)
Why are you seeking an evaluation? (Select all that apply.)
*
Depression
Anxiety
Panic Attacks
Bipolar Treatment/Evaluation
Problems Managing Anger
Problems Managing Stress
Substance Abuse/Chemical Dependency
Eating Disorder
Other Addiction
Other (not in this column)
(Select all that apply.)
*
Dementia
Competency/Guardianship
Occupational Dysfunction/Disability
Court-Ordered Evaluation
Other Legal/Forensic
Insomnia
ADD/ADHD (children, adolescents)
Adult ADD
Elective Pre-Surgical Clearance (bariatric, plastic)
Fitness-for-Duty Evaluation
Other (not in this column)
Specific Referral Source:
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CURRENT Psychotropic Medications (include DOSAGE)
*
If you are currently taking psychotropic medications, please list them here, along with their doses and indications. Otherwise, indicate "NONE."
Other Current Prescription & OTC Medications
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Include dosages and OTC (over-the-counter) medications. Indicate if "NONE."
I am interested in scheduling an appointment:
*
As soon as possible: Next Available
First Available (within 2-3 Days)
5-7 Days (< 1 week)
1-2 weeks
Comments
*
Please include a brief description of the reason for your visit, any special needs or specific questions you may have, and the best time of the day to reach you. If you are not the patient, please explain your relationship and indicate in what capacity you are wishing to set an appointment.
Submit
MEET DR. SILVA
NEW PATIENTS
COST OF TREATMENT
Patient Reviews
REQUEST AN APPOINTMENT
ADULT ADD/ADHD?
Frequency of Visits
Frequently Asked Questions
THE CONCIERGE MODEL
WHAT IT IS
Concierge Reviews
TELEMEDICINE
WHAT IT IS
HOW IT WORKS
PATIENT REVIEWS
TREATMENT PHILOSOPHY
INFORMATION FOR PATIENTS & THEIR FAMILIES
ARCHIVES
CONTACT
ABOUT
PAYMENTS
REFILL POLICY
CANCEL/NO-SHOW
PRIVACY
FORMS
RECOMMENDED