Please use full legal name of the patient, no nicknames.
Please use full legal name of the guarantor (the person or insured name responsible for the bill), no nicknames.
Please bring your insurance ID card in with you. The receptionist will need a photocopy.
Select symptoms you currently have, or have had in the past year.
Select conditions you have had in the past.
Click in the text field to view list. Add unlisted surgeries by typing the name and pressing enter.
Use the form below to list the medications you are currently taking. If you're unsure, you may leave this blank and bring your medications with you on your first visit.
Use the field below to list the allergies you have. Press enter to complete an allergy's name.
Please confirm that you have no allergies before continuing.
I have no allergies
Use the form below to list applicable family history.
Select which of the following you use, and indicate the amount used.
Please enter your current occupation.
Use the form below to list the immunizations you have received.
By submitting this form, I agree that this information is complete and accurate. I also understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.
We hope this online registration form made the process easier for you! We will have you sign a printed version of this form, with the information you provided, when you arrive at the office.
If there were any medications you were unsure about, don't forget to bring either a list of them or the medications themselves with you when you come.
If you haven't already done so, please call us (817-453-5912) in order to setup your appointment.
We look forward to serving your medical needs!
Optionally, you may download the health history section of registration form, with your information filled in, below. You can keep it for your personal records, or in case you need it for a referral doctor. For security, this is only available for download now, and can only be downloaded once.
Click in the text field to view list. Add unlisted cancers by typing the name and pressing enter.
Click in the text field to view list. Add unlisted fractures by typing the name and pressing enter.
Click in the text field to view list. Add unlisted STDs by typing the name and pressing enter.