| All fields marked with * are required. |
How to become a new patient with Houston Thyroid and Endocrine Specialists
We would like to make you aware that one of the providers, Dr. Jogi, has extensive availability for new and established patients from 4:30 am to 9:30 pm AS TELEVISITS. HE ONLY WILL BE PHYSICALLY IN OFFICE FOR PATIENT VISITS ONE WEEK EVERY 2 MONTHS for follow up patients. New patients will see Dr. Jogi as a televisit from home or from the office if preferred. There is pre-visit work/communication conducted by Dr. Jogi in the 2-7 days prior to all upcoming appointments. If you have a strong desire for frequent office visits please see another doctor. All patients must have a Primary Care Physician (PCP) as none of the Houston Thyroid providers will act as a PCP.
The form can take about 10 minutes to complete Be prepared to enter information from your health insurance card and from medical records if you have them.
At the end of the online forms you will be given detailed instructions to self-schedule an office visit online. If you don't get an appointment that you desire please contact the office to request to be placed on the cancellation wait-list.
You may confirm if we are in-network with your insurance by contacting the number on your card and checking our website which also shows transparent self-pay rates.
- If you have difficulty with this online form then please come to our office during regular business hours to complete it on a computer in our office -- there are no paper copies of this form. Completion of the form does not establish patient-doctor relationship until face to face meeting.
- Please use an updated web browser (Chrome, Firefox, Safari, and the Microsoft Edge browser). The form will time-out after 90 minutes of inactivity.
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*INSURANCE APPROVED REFERRAL CODE FORM
Please upload images of your approved insurance referral code ("Request ID", "Certificate number", etc). This is a code and form generated by your insurance company after your primary care doctor has requested the code from them. Houston Thyroid cannot see you unless we have received this form at least 4 days prior to your visit. It must be valid for our place of service and approved for specific dates.
Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file. |
* What is the primary reason for your visit with an endocrinologist? | |
* IMPORTANT: Please select ALL of the reason(s) for your visit. Select all that apply from the following. |
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Please upload your last thyroid blood tests by attaching screen shots of the results.
Please click "choose file" to select a file. You may upload up to five files. (photo files .jpg .png .bmp work best- you can take picture of the forms with your phone and then attach those photos directly or email the photos to your computer and attach from the download section on your computer) After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Please attach your bone density report(s)
Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Upload your last sets of thyroid labs as image files .jpg, png, or .bmp. (just send screen shots)
Please click "choose file" to select a file. You may upload up to five files. (photo files .jpg .png .bmp work best- you can take picture of the forms with your phone and then attach those photos directly or email the photos to your computer and attach from the download section on your computer) After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Ahead of your visit please attach your last thyroid labs, or fax results to 713.795.0855, or upload from your desktop for the doctor to review with this link. Upload data here
Please click "choose file" to select a file. You may upload up to five files.(photo files .jpg .png .bmp work best- you can take picture of the forms with your phone and then attach those photos directly or email the photos to your computer and attach from the download section on your computer) After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Please upload your last thyroid ultrasound report by attaching a screenshot of the report, or fax results to 713.795.0855, or upload from your desktop for the doctor to review with this link. Upload data here
Please click "choose file" to select a file. You may upload up to five files. (photo files .jpg .png .bmp work best- you can take picture of the forms with your phone and then attach those photos directly or email the photos to your computer and attach from the download section on your computer) After selecting the file, click the upload button to upload them. Click the X to delete a file. |
File Upload of the thyroid pathology report. (Screen shots)
Please click "choose file" to select a file. You may upload up to five files. (photo files .jpg .png .bmp work best- you can take picture of the forms with your phone and then attach those photos directly or email the photos to your computer and attach from the download section on your computer) After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Ahead of your visit please attach your last diabetes labs (hemoglobinA1c, lipids and blood creatinine) , or fax results to 713.795.0855, or upload from your desktop for the doctor to review with this link. Upload data here
Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Please attach images of all your previous blood calcium results, any previous bone density examination reports.
Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file. |
We do not have access electronically to any of your old records from other doctors. Ahead of your visit please upload your adrenal imaging results here now, or fax to 713.795.0855, or upload from your desktop for the doctor to review with this link. Upload data here
Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Ahead of your visit if you have any results, please attach your last testosterone labs, or fax results to 713.795.0855, or upload from your desktop for the doctor to review with this link. Upload data here
Please click "choose file" to select a file. You may upload up to five files.(photo files .jpg .png .bmp work best- you can take picture of the forms with your phone and then attach those photos directly or email the photos to your computer and attach from the download section on your computer) After selecting the file, click the upload button to upload them. Click the X to delete a file. |
Please attach the pituitary MRI report
Please click "choose file" to select a file. You may upload up to five files. After selecting the file, click the upload button to upload them. Click the X to delete a file. |
| *We will likely order blood work for you. Usually we order via any national laboratory such as Labcorp and then have patient return 2-4 weeks later to review results with the doctor. . If you have a preference please select one of the following: | |
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