Virtual Consultation

PRMA can consult with you virtually before you come to see us.

Option #1: Fill out this form. (Upload current photos.)
Option #2: Print and fill out our Patient Information form.  Fax to 210-641-7577 or mail the form to our office.

Patient Information

Primary Insurance

Scan or Take a photo of the front and back of your insurance card and upload it on this secure form.
You can also fax it: 210-641-7577

Secondary Insurance

Scan or Take a photo of the front and back of your insurance card and upload it on this secure form.
You can also fax it: 210-641-7577

Doctors

Patient History

lbs
ft. in.
example: x packs a day/week
example: x glasses of wine/beer a day/week
example x cups of coffee a day
example: x months
include year with each procedure listed

Health History

  Yes No
Diabetes
Hypertension
Emotional Problems
Deep Vein Thrombosis
Blood Clotting Disorders
Lupus or Rheumatoid Arthritis
Raynaud's Syndrome
Migraine Headaches
Abdominal Surgery Scars
Keloids
HIV
Hepatitis A, B, or C
Other
include the name from the list on the left in your explanation

Family History

  Yes No
Deep Vein Thrombosis
Breast Cancer

Surgery

Photos

Example Photos