JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
APPOINTMENT / TELE-VISIT REQUEST
In an Emergency, Call 911.
If you have an Urgent medical need, or are seeking a same-day appointment, please call our office - 469-645-1155. WE ACCEPT ALL MAJOR INSURANCES & MEDICARE, TRICARE
Appointments E-mail:
staff@rhvcare.com
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Desired Location
TELE MEDICINE VISIT (via Phone/Video Chat)
Lewisville Clinic
DentonClinic
Other:
Clear selection
First Name
*
Your answer
Last Name
*
Your answer
Phone no
*
Your answer
E-mail ID
Your answer
Insurance Provider
Your answer
Insurance Member ID
Your answer
Insurance Group ID
Your answer
Secondary Insurance (If any)
Your answer
Your Primary/Family doctor's Name and office info
Your answer
Certain insurance plans require a referral from your primary care provider. Ensure you have referral submitted to us timely manner prior to your appointment.
My insurance doesn't need referral from primary/family doctor.
I requested referral from my primary/family doctor.
I am not sure if my insurance requires a referral.
I do not have a primary/family doctor.
Clear selection
Next
Page 1 of 2
Clear form
Never submit passwords through Google Forms.
This form was created inside of SIVA P. SONTINENI, MD, PA.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report