New Patient Registration Form V2

Let's first get to know you

Basic Demographics
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemale
Social Security
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Please have your mobile phone close by. Enter your cell phone number below and click CONFIRM. You will have to enter a confirmation number to move on to the next page.
I have my mobile phone close by*

YesNo
Cell Phone*
Cell Phone Number*
Home Phone
Email*
example@example.com
The state of Texas now requires that we send your prescription electronically, please indicate your preferred pharmacy. (ie. CVS on new braunfels in Alamo heights or Amazon phamacy or CVS inside of target on 1604 or something like that that we can use to identify the location). Failure to include identifying information about your pharmacy may result in your prescription sent to the incorrect location.
Preferred Pharmacy*
make sure to INCLUDE CROSS STREET or some way for our staff to identify the location

Insurance Information
Even though one or more of the conditions that you have selected is generally considered not to be medically necessary and will not be covered by your insurance company, we would like like to collect your insurance information in case some of your future services may be considered medically necessary.
Do you have medical insurance?*

YesNoI'm an attorney or workman's compensation patient
Primary Insurance*
Group number
Member ID*
Subscriber's Name*
Subscriber's date of birth*

MonthDayYear
Date
Do you have additional secondary insurance?*

YesNo
Secondary Insurance
Member ID
Group number
Subscriber's Name
Subscriber's date of birth

MonthDayYear
Date
Work Related Injury

Treatment of your work related injury requires that we obtain all of this information. Please fill out in as much detail as you can provide.
Date of Injury*

MonthDayYear
Date
Claim Number
Case Manager Name and Information
Name and Contact information
Fax Number for Case Manager
Employer
Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Employer Phone Number
Adjuster Name and Contact Info

Your Social History

This will help us get to know you better
Your Photo (selfie)
Your Driver's License (back facing camera)
Occupation*
Handedness*

Right hand dominantLeft hand dominantBoth hands equivalent
Marital Status
How many children do you have?
Your Current Weight and Height*
Social Media

Let us follow you on social media. You will be notified of our discounts and specials.
Are you on these platforms?

InstagramFacebookTwitterSnapChat
Instagram Handle
ie. @STARSPlasticSurgery
Facebook username
ie. @STARSPlasticSurgery
Twitter username
ie. @STARSPlasticSurgery
You're almost done!! After you hit the "Next - Required Forms" icon below, your information entered above will be sent to us. You will also be taken to the next page where there are some mandatory forms that you have to sign that will give us permission to treat you.
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New Patient Registration Form