• New Specialty Service Registration

  • Please allow 10 minutes to complete your registration forms.  If you have health insurance, we have included a field to submit copies of your card.

  • Personal Information

  • What services would like to discuss with your Personal MD provider? Mark all that apply.
  • Which provider would you prefer to see?
  • Who is the patient?
  • Patient's gender*

  • Contact Information

  • Format: (000) 000-0000.
  • What method would like us to use to contact you (mark alll that apply)?*
  • Can we leave detailed message when we call you?*

  • Emergency Contact Information

  • Would you like to add an Emergency Contact?
  • Relationship to your Emergency Contact
  • Format: (000) 000-0000.
  • Would you like to add a second Emergency Contact?
  • Relationship to your second Emergency Contact
  • Format: (000) 000-0000.

  • Health Insurance

  • Do you have medical insurance?*

  • Speed up your first visit by providing us with your insurance information before your visit.  If you have your insurance card, please provide pictures below.

  • Please include a picture of the front of your insurance card.
  • Please include a picture of the back of your insurance card.

  • Release of Medical Information

  • Would like to add someone we can share your medical information with?
  • Format: (000) 000-0000.

  • Personal MD Policies

    Scroll down on each section to read each policy in full.

  • General Patient Agreement and Disclosures for Treatment

    The following section includes your rights and responsibilities as a patient of Personal MD

  • Specialty Service Agreement

    Below is the agreement for our primary care members

  • Speciality Service Agreement

    This agreement is for patients who want to be seen for our specialty services (weight loss, hormone therapy, or aesthetic services).  This agreement is not for clients who would like Personal MD to provide primary care services.  Please call our office if you have questions. 

    1.  Personal M.D. Family Healthcare, P.A. (Personal MD or Clinic) is a Direct Primary Care practice as defined by Texas Occupation Code 162 Subchapter F. The captions in this agreement are only for convenience and have no legal meaning.  


    2. Legal Significance. I acknowledge that this agreement is a legal document that gives the parties certain rights and responsibilities. I have been given reasonable time to seek legal advice regarding this agreement and am satisfied with its terms and conditions.


    3. Governing Law and Venue: This agreement shall be governed and construed under the laws of the State of Texas. The parties agree that the Texas state and federal courts in Collin County shall be the exclusive courts of jurisdiction and venue for any legal action, particular proceeding, or other proceeding that may be brought, or arise out of, in connection with, or because of this agreement. The parties waive any venue rights in any other courts they might otherwise have.


    4. Entire agreement: This agreement contains the entire agreement between the parties and replaces any earlier understandings and agreements, whether written or oral.


    5. Change of Law: If any relevant law, regulation, or rule changes at a federal, state, or local level affect the terms of this agreement, the parties agree to amend this agreement to comply with the law.


    6. Severability: If a court of competent jurisdiction considers any part of this agreement legally invalid or unenforceable, that part of this agreement will be amended to the extent necessary to be enforceable, and the remainder will be in force as originally written.


    7. Notice: This Specialized Service Agreement does not constitute health insurance and is not a medical plan that provides health insurance coverage for purposes of the Patient Protection and Affordable Care Act.  


    8. Specialized Services: Specialized Services include evaluating and managing Hormone Therapy, Weight Loss, and Aesthetic services. Personal MD may change the list of services defined as a specialized service without first notifying me.  


    9. Primary Medical Care: I understand that I am not establishing a Primary Care relationship with Personal MD or its providers or medical staff. As such, a Personal MD will not provide medical care for acute, chronic, or preventive reasons unrelated to Specialized Services.


    10. Medical Recommendations: Personal MD providers and staff may recommend testing and treating medical problems unrelated to a Specialized Service. If such recommendations are made, I understand that Personal MD is not responsible for evaluating, following up on, or treating primary care medical conditions, and any recommendations should be discussed with a primary care provider.


    11 Medical Records: By signing a medical records release form, I can request that any medical records created and collected by Personal MD be sent to my outside physician.


    12. Converting to a Primary Care patient: If I desire to establish a primary care relationship with Personal MD, I must agree to the Medical Service Agreement and the Medical Billing Form. All Registration Fees, Pro-rated Fees, and any related charges must be paid before a primary medical care relationship can be established.


    13. Term: I am considered an active patient on the last day I was seen in person by a Personal MD medical provider, plus two years. If I desire to see a Personal MD provider for any medical service greater than two years from the last day I was seen in the office, I will need to establish myself as a new pat. Ind I will be responsible for all charges required to reactivate my account.  


    14. Construction: If an ambiguity or a question of intent or interpretation ar. In that case,ses, this Medical Service Agreement shall be construed without regard to any presumption or rule requiring construction or interpretation against the party who drafted the contract.


    15. Served: All written notices are deemed served when notification is delivered by U.S. mail to the address written in the original "Personal Information Form" or the "Update Address Form."


    16. Confidentiality: Member understands this agreement is not considered part of a medical record, and terms and conditions of this agreement will not be transmitted to any other party if copies of all or part of your medical record are transmitted.


    17. Original Copy: A photocopy or scanned copy of this Specialized Service Agreement will be considered an original.


    18. Certification: With your signature below, you certify that you have read this entire agreement and have been allowed to ask questions and receive answers about all its provisions. Personal MD will keep a digital copy of this agreement, and a printed copy is available upon request at no charge.

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: