Vintage Oaks Concierge Medicine

Emergency notice: We do not provide emergency services. For emergencies call 911 or go to the nearest emergency department.

Privacy: This secure intake is intended for non-emergent care coordination and planning. Please complete all sections as accurately as possible.

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Patient Info

Full legal name

Preferred name

Date of birth

Phone

Address

Preferred contact method(s)

Text

Phone

In-person

Emergency Contact & Providers

Emergency contact name

Relationship

Emergency contact phone

PCP name / practice

PCP phone/fax

Specialists (list)

Preferred pharmacy

Pharmacy phone

Insurance (for coordination only)

I have insurance

I do not have insurance

Insurance company

Member ID / Group #

Concerns & History

Main concerns / goals

Medical history (check all that apply)

Hypertension

Diabetes

Heart disease

Stroke/TIA

Asthma/COPD

Thyroid disease

Autoimmune condition

Mental health condition

Chronic pain

Cancer

Other

Surgical / hospitalization history

Current medications (include OTC + supplements)

Allergies / reactions

Consents

Please read and confirm the items below.

Telemedicine informed consent

Telemedicine may limit physical examination. Your clinician may recommend in-person care. Not for emergencies. You may withdraw consent at any time.

I consent to receive care via telemedicine.

Medication management & controlled substances

Prescribing follows Texas and federal law. Schedule III–V may be used; Schedule II is limited and may require in-person evaluation and is never guaranteed.

I understand and agree to the medication management policy.

HIPAA authorization (care coordination)

Authorizes exchange of PHI with your PCP, specialists, pharmacies, labs/imaging, and insurers for coordination.

I authorize release/exchange of my information for care coordination.

Concierge services agreement

Concierge services are not insurance and not emergency services. Fees (if any) are separate from insurance. Administrative support does not guarantee insurer approval.

I acknowledge and agree to the concierge services terms.

Communication consent

Text

Phone

Electronic communication may carry privacy risks.

Typed signature (full name)

Date

By typing your name, you are signing this intake and consent packet electronically.