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Telemedicine?
WHAT IT IS
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FAQ
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Patient Name
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First
Last
If you are not the patient, please explain in the comments section below.
TELEPHONE Area Code:
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*
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Address (TEXAS only)
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Line 1
Line 2
City
State
Zip Code
Country
Date of Birth
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MM/DD/YYYY
Age
*
E-mail
*
Please Confirm:
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Dr. Silva may use this e-mail address to notify me of appointments.
ENTER PHARMACY NAME, and
TEXAS
ADDRESS.
All prescriptions are sent electronically
PREFERRED PHARMACY
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Line 1
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City
State
Zip Code
Country
USE STREET ADDRESS OR PHONE NUMBER
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 FAQ 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.)
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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)
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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:
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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.
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