The Second Opinion Hotline Form

Please complete this form as completely as possible before submitting. Dr. Tips will review the information ONLY if you have a valid password. You will receive a speedy reply via e-mail, so please be sure your e-mail address is typed carefully.

We endeavor to respond to all enquiries within two working days. If however you require an urgent response please telephone us.

Phone: 512-328-3996
Fax: 512.263.7787
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Please Enter Your Password

Your Name

Your E-mail Address

Telephone

Fax

How Would You Prefer to be Contacted? By Phone By E-mail

Patient's Name/I.D.

Patient's Gender: Male Female

Patient's Chief Complaints (brief diagnosis)

Specific Information About Highest Priorities:

Additional Notes/Observations: