RPC New Appointment Request
This appointment request form is confidential. In compliance with the Health Portability and Accountability Act "HIPAA" (rule 104-91), please know that communications over the internet are not guaranteed to be secure.  There exists a possibility that information you include in this form can be intercepted and read by other parties besides the staff at RPC. Please call us at 512-982-4116 if you prefer to request an appointment by phone.
Sign in to Google to save your progress. Learn more
Name: *
I am not currently in a crisis. (If you are currently in a crisis, please call 911 or go to the nearest ER) *
Required
I understand that Reproductive Psychiatry and Counseling is not in-network with any commercial health insurance plans. *
We accept HSA/FSA card payments, and provide superbills for patients to request reimbursement from their health insurance provider. Patients are responsible for appointment payments. RPC has no control over whether or not a health insurance plan will cover appointment costs. Please call our clinic if you would like more information.
Required
Are you interested in learning more about therapy?
Clear selection
Are you interested in learning more about medication?
Clear selection
Is there a specific provider that you would like to see?
Please provide a brief description of what brings you to our clinic at this time.
Please check all of the following which are applicable
How were you referred to us?
How would you prefer to be contacted regarding this request? *
Required
If by phone or text, what is the best number to reach you at? *
If by phone call, when is the best time to call?
Do you consent to receiving voicemails regarding your request? *
Required
What is the best email address to reach you at?
What is your date of birth?
MM
/
DD
/
YYYY
What is your zip code?
What gender do you identify with?
Do you have Medicare or plan on obtaining Medicare within the next year?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Reproductive Psychiatry and Counseling. Report Abuse