Patient Consideration

Concierge Mental Health Psychiatry for Adults and Geriatric Individuals

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THIS FORM MUST BE COMPLETED BY THE POTENTIAL PATIENT AND/OR LEGAL GUARDIAN: IT MAY BE COMPLETED WITH THE ASSISTANCE OF ANOTHER PERSON AS LONG AS THE PATIENT AGREES WITH ALL THAT IS STATED AND VOLUNTARILY SIGNS THE BOTTOM OF THE DOCUMENT WITH THEIR TYPED NAME AND EMAIL ADDRESS

Psychiatric Pre-Consult Questionnaire – Potential New Patient

I agree with all of the above and understand that this is not an all-inclusive list of all the office policies. More details are found in the registration forms provided prior to the initial comprehensive medical evaluation.

I accept and understand that this web form submission is part of an application for a non-urgent outpatient psychiatric consultation and does not constitute a doctor-patient treatment relationship. The information I am providing on this form and during my complementary 10 minute pre-consult will help Dr. Philias decide if an outpatient consultation with her is appropriate or if a different referral will better serve my needs.

If my situation is life-threatening, or an emergency that cannot wait for a response, I should call 911 or go to the nearest emergency room instead of submitting this form.

I understand that this submission will not be reviewed after hours or when our clinical psychiatric team is out of the office.

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WellMind

Dr. Alla Weisz Board Certified Family Medicine Concierge Physician in Palm Beach Gardens, FL

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