Accepting new patientsTexas residents onlyWe do not accept MedicaidNow open: North Dallas office
Online patient form

New Patient Questionnaire

Fields marked * are required. Your answers are sent securely to our intake team — nothing is stored in your browser.

How did you hear about our clinic?
Personal Details
Race
Ethnicity
Marital Status
Smoking Status
Primary Contact Details
Primary Phone
Emergency Contact
Allergies
Supplements

History of Present Illness

Past Medical History

Past Psychiatric History?
Past Medical History?
Past Medications: Please list ALL medications you have been on in the past
Current Medications: Please list ALL current medications
H/O Head Injury or Seizures or TBI?
Allergies?

Family History

Family History?

Social History

Tobacco
Alcohol
Substances, Other
Abuse and Trauma
Current Living Arrangements

Your submission is emailed securely to our intake team. This form is not for emergencies.

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