Request A Virtual Visit | Texas Family Physicians

Name*
First Last
Date of Birth (dd/mm/yyyy)*
MM slash DD slash YYYY
Phone Number*
Email*
Reason for visit:*
Preferred day:*
Preferred time:*
Additional Info:
Terms and Conditions:*
I Agree
Terms: Pre visit registration via Phreesia must be completed and a valid credit card on file, you will get a text and email with the registration. Any copayment or balances must be paid while registering. We will bill your insurance for your visit, but if denied, a $125 charge will be charged to your credit card.