| All fields marked with * are required. |
Thank you for choosing our practice. Please complete this "new patient packet" in order to register. At end of the packet, you will be given instructions to schedule your own appointment. If you have questions please contact us at 713.952.8400
- Fill in answers, then press "Next" at the bottom right of each page. If you have health insurance please have the card in your hands before starting since we will need that information.
- On the last page after you press "Submit" you can Print/save a copy when finished for your records and we will also automatically receive it electronically
- After you complete this form, then please self-schedule your appointment or you may contact us to schedule your appointment. The purpose of the appointment is to evaluate the patient so the physician can determine if he/she can accept her as a patient - not necessarily for treatment.
If you have difficulty with this online form then you can come to the office to complete it on one of our computers or download a copy at the bottom of this link to print, then mail or fax it to us
Note: For your best reliability while filling out the form, please use a web browser that is up to date. Browsers which meet current security standards are Chrome (recommended), Firefox, Safari, and the Microsoft Edge browser. The form will timeout after 90 minutes of inactivity; please make sure you have your insurance information ready and be prepared to fill out the form in one sitting.
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* IMPORTANT: Please select the main reason for your visit. | |
| *Are you seeing us because another doctor specifically recommended you come to a dermatologist? | |
| *Patient Title: | |
| *Patient’s LAST Name: | |
| Make sure this is the last name of the patient who will be seen by the doctor. If patient is using health insurance It must match exactly the official patient name listed on their insurance card. |
| *Patient’s FIRST Name: | |
| Make sure this is the first name of the patient who will be seen by the doctor. If patient is using health insurance It must match exactly the official patient name listed on their insurance card. |
| *Patient date of Birth: | |
| *Patient Address Line 1 | |
| Patient address line 2 | |
| *City | |
| *State | |
| *Patient Zip Code: | |
| *Primary phone number | |
| We strongly recommend using your cell phone as the primary phone. THIS CELL PHONE NUMBER WILL BE USED FOR MOST COMMUNICATION WITH THE OFFICE. PLEASE ENSURE THE CELL PHONE NUMBER IS CORRECTLY WRITTEN FOR THE PATIENT TO RECEIVE OFFICE COMMUNICATION VIA A SMS COMMUNICATION SYSTEM CALLED KLARA (https://patient.klara.com). If a cell phone number is not entered, then the patient is required to communicate with the office by US Mail or fax. We require written communication with the office. |
| *Is your cell phone number the same as your "primary phone number"? | |
| *Patient’s Email Address: | |
| *Sex at Birth: | |
| *If you selected other please elaborate | |
| *Responsible Party (This is the person who will be paying for the visit): | |
| *Is the patient aged 18 or older? | |
| Emergency contact: please list a person who is not located in the same household. Examples: brother, father, mother, sister, friend. |
| *Name of emergency contact | |
| *Relationship to patient | |
| *Phone number for emergency contact | |
| *Primary Care Provider Name: | |
| *Primary Insurance Type: | |
Please attach image of the HMO referral authorization code which is required by your insurance.
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. |
| *Patient Marital Status: | |
| *Patient Languages spoken. Check all that apply: | |
| Names of other languages spoken | |
| *May we leave a detailed message on your phone for test results? | |
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