Health Intelligence Report Sign-Up

Patient Information

First Name *

Middle Name

Last Name *

Do you have a previous LAST name?

Adding names increases our ability to find all of your medical records at other doctors' offices.

Yes

Do you have a previous FIRST name?

Yes

Company with TextCare Access *

Please enter the name of the company that makes you eligible for TextCare.

Relationship to the company providing TextCare and the Health Intelligence Report *

Phone Number *

I authorize you to text me about my health

Personal Email Address *

We will send a confirmation to this email

Current Address *

Date of Birth *

Sex at Birth *

Female

Male

Race *

Ethnicity *

Emergency Contact

Emergency Contact's First Name *

Emergency Contact's Last Name *

Emergency Contact's Phone Number *

Relationship to Your Emergency Contact *

My emergency contact is authorized to discuss my health

Would you like to add another representative who is authorized to discuss your health?

An authorized representative can message and speak with TextCare providers on your behalf, typically a spouse, partner, or care giver.

Yes

Recent Physical, Labs, and Health Questions

Please share any health questions or concerns you would like to discuss during your Health Intelligence Consult.

Have you had a recent physical or labs?

Yes

Would you like us to order labs for you?

We'll discuss options if you choose to order labs.

Yes, order labs

Medical Details

Height (feet) *

Height (inches) *

Weight *

Do you have any allergies to medications? *

Yes

Are you currently taking any medications? *

Yes

Please select any medical conditions you have. *

Anemia

Anxiety

Asthma

Bipolar Disorder

Cancer

COPD

Depression

Diabetes Type 1

Diabetes Type 2

High Blood Pressure

High Cholesterol

Insomnia

Reflux

Seasonal Allergies

Sleep Apnea

Thyroid Condition

None - No medical conditions or ongoing treatments

Other

Please list any other medical conditions or treatments.

Have you had any significant medical events, surgeries, or procedures? *

Please share any significant events from any time in your life.

Yes

Women Only (if applicable)

Pregnant

Breastfeeding

Hysterectomy

Do you smoke or vape? *

Yes, I do both

Yes, I smoke

Yes, I vape

Former smoker

Former vaper

Do you consume alcohol? *

Yes

Former

Data Sharing

Health Information Exchange (HIE) Consent

I authorize the electronic sharing of my health information with other authorized healthcare providers and organizations through secure, national health information networks.

This may include clinical data such as:

Diagnoses
Medications
Lab and test results
Imaging reports
Allergies
Encounter notes
These records may be shared and accessed for purposes of treatment, care coordination, and related healthcare operations.

I understand that:

Only healthcare providers or organizations with a treatment relationship with me may access my information.
Sharing this information can improve the continuity, quality, and safety of my care.
All data exchanges will be conducted in compliance with federal and state privacy laws, including HIPAA
This consent remains valid until I revoke it in writing at any time.

I consent to health information exchange via HIE services

Verify your identity to access your full health record

We use Vouched, a secure, industry-standard identity verification service, to confirm your identity. Vouched verifies your information and returns a confirmation—we do not store your ID or selfie. Once verified, your TextCare provider can share more complete health information from other doctors and facilities with you. This step is optional. If you run into any trouble, you can skip it for now and complete it later.

Please fill in First Name, Last Name, Date of Birth, Email, and Phone before verifying.

Signature *

By signing this form, you agree to the below consent agreements. Please refer to the agreements for complete Consent to Treatment, Communications Consent, Notice of Privacy Practices, and other policies.

Treatment, Consent & Notice of Privacy Practices