Online New Patient Contact Form

1
Contact Name:* This field is required.As it appears on your insurance card or government ID
First Name
Last Name(s)
2
Best Contact Number:* This field is required.
Please enter a valid phone number.
3
Medical Insurance Provider:* This field is required.
Aetna
Blue Cross Blue Shield
Cigna
Humana
Medicaid
Oscar Health
Prime Health
Superior
TRICARE
United Healthcare
Self-Pay / Private Pay
Other
4
What is the name of your health insurance provider?* This field is required.
5
Type of Insurance (typically stated on your insurance card)* This field is required.
HMO, or Health Maintenance Organization
PPO, or Preferred Provider Organization
EPO, or Exclusive Provider Organization
POS, or Point of Service Plan
Other or Unknown
6
Do you currently carry any form of Medicaid insurance coverage?* This field is required.Primary, Secondary, Tertiary Insurance
YESNO
7
What is your date of birth?* This field is required.This is required to book an appointment
Date
Month
Day
Year
8
What is your preferred method to be contacted by our staff?* This field is required.
Phone Call / Voicemail (please ensure voicemail is set up for number given)
Text Message (please ensure number given is able to receive SMS messages)
9
How soon do you need a new patient appointment?* This field is required.New patient appointment availability varies by medical provider.
Within the week
Within 2 weeks
Within 3 months
Within 6 months
Within 12 months
10
Is there a specific provider(s) you wish to schedule your appointment with (if he/she has availability within the time frame needed)? You can find out more about our providers by clicking here. Choose any that apply.* This field is required.New patient appointment availability varies by medical provider.
No preference and/or soonest appointment available
Ms. Elieth (Ellie) Jaramillo, PA-C (Certified Physician Associate)
Ms. Gissell Garza, PA-C (Certified Physician Associate)
Ms. Andrea Tijerina, PA-C (Certified Physician Associate)
Currently not taking new patients - Samuel N. Landero, MD
11
What days of the week and times of days work best for your schedule? IMPORTANT: New patients must arrive 30 minutes prior to appointment to fill out paperwork and to verify insurance.* This field is required.Check all that apply
No preference, soonest appointment available
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
First appointment of the day (9am - arrive at 8:30am)
Mid-morning
First appointment after lunch (2pm - arrive at 1:30pm)
Mid-afternoon
Last new patient appointment of the day (3:30pm - arrive at 3pm)
12
If you selected to be contacted via phone call / voicemail or if we need to contact you to collect additional information, when are the best days and times to call you Monday through Friday, 8am - 5pm?* This field is required.
13
Terms and Conditions* This field is required.
14
How did you hear about us?* This field is required.
Should be Empty: