Patient Assistance Request

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GCLID

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GCLID Date

Fill out this form and a member of our team will reach out within one business day. We're available 7 days a week, 8 am to 8 pm CST.

If you need to schedule, reschedule, or cancel an appointment, pick that option below and include your preferred times.

Prefer to call? (512) 956-5003

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

Effective 7/31/25: Check out our all new Quick Scheduler where you can now schedule, move, and cancel your appointments without using this form anytime at: https://schedule.televerohealth.com/

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

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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:*

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Do you need to upload a file?

Yes

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File

Max. file size: 50 MB.

Form_Submitted_Date

Unique ID