Book An Appointment If you are human, leave this field blank. First Name * Last Name * Phone Number * Email * Gender Male Female Referred By Chief Complaint * Symptoms Present for * Days Weeks Months Years I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Texas Center for Digestive Health and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Texas Center for Digestive Health. I consent to the use and disclosure of my/the patient's protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with the Texas Center for Digestive Health of Privacy Practices. * I Agree I consent that this is not a life-threatening emergency, if it were, I would call “911” or proceed to the nearest emergency department. * I Agree Submit
