Patient Assistance Request

If you are a patient and you require any assistance, please complete this form.

A Televero Health representative will contact you, usually within one business day during our normal business hours: 8:00am – 8:00pm Monday – Saturday.

Phone: (512) 956-5003
Fax: (512) 233-0553

Existing patients can request an appointment by selecting the option “Schedule/Reschedule/Cancel an Appointment” and choose the days and times you prefer to be scheduled.

A member of our team will then contact you to confirm availability.

"*" indicates required fields

My name is:*

First Last

I am a:*

A new patient

An established patient

I need assistance with:*

is this for your first appointment?*

Yes

I need to:*

Schedule a new appointment only

Cancel an existing appointment only

Cancel an existing appointment and schedule a new appointment

What is the date of the appointment you want to cancel?

Month

Day

Year

Choose your preferred appointment times

If you would like to schedule or reschedule an appointment, please select the day and timeslots you can be available.

Monday

Morning 8a-12p

Afternoon 1a-5p

Evening 5p-7p

None

Tuesday

Morning 8a-12p

Afternoon 1a-5p

Evening 5p-7p

None

Wednesday

Morning 8a-12p

Afternoon 1a-5p

Evening 5p-7p

None

Thursday

Morning 8a-12p

Afternoon 1a-5p

Evening 5p-7p

None

Friday

Morning 8a-12p

Afternoon 1a-5p

Evening 5p-7p

None

Saturday

Morning 8a-12p

Afternoon 1a-5p

Evening 5p-7p

None

This field is hidden when viewing the form

Section Break

Here are some more details about what I need assistance with:

Note: If you need to cancel or reschedule any appointment(s), please provide the date(s) so that we can assist you quicker.

My mobile phone number is:*

My email address is:*

This field is hidden when viewing the form

Do you need to upload a file?

Yes

This field is hidden when viewing the form

File

Max. file size: 50 MB.

Form_Submitted_Date

MM slash DD slash YYYY

Unique ID