Patient Application

Patient Information

Most patients are 7 years of age or older. A new form must be filled out for each patient.

Name:
Gender:	Male Female
Address:
Apt #:
City:
State:
Zip:

Responsible Party Information

If you already have a child in treatment or have submitted this form previously just fill out your first and last name in this section.

**This information should be the insurance subscriber
**If Medicaid the information that is provided on your card should be in this area.

	Self Father Mother Guardian
Name:
Address:
Apt #:
City:
State:
Zip:

	Self Father Mother Guardian
Name:
Address:
Apt #:
City:
State:
Zip:

Health History

	Patient has NO known medical issues:
	Patient is currently taking Medications:

	Patient has blood disorder or other medical disorders:

	Patient has special healthcare needs:

Contact Information

	Self Father Mother Guardian
Name:
Home:
Work:

	Self Father Mother Guardian
Name:
Home:
Work:
	Please contact me to schedule.
	Self Father Mother Guardian
	Home Work

This information is private and confidential and is restricted to office use only. This information may be used to verify patient eligibility and/or benefits. It is your responsibility to inform this office of any medical or information changes.

Please review all your information carefully BEFORE submitting to our office. If you have any questions please contact us with the information provided on the "Contact Us" page in this site. Thank you!

4222 Trinity Mills Road, Suite 250 • Dallas, TX 75287 • Phone: 214.646.0870 • Fax: 214.646.0875 • Email Us

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