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Phone: 817-416-6155

New Patient Forms

We ask that new and established patients complete or update their patient registration annually. Patients can complete this process by either logging into the secure patient portal or downloading the following forms. Click on the title of each form below to download them. 

1. Patient Registration Form
2. Patient Authorized Consent
3. Office Policies and Procedures Form
4. Medical Past History Form 
5. Current Medical History Form
6. Only Medicare Patients Screening Form
7. Authorization to Treat a Minor Form
8. HIPAA Disclosure 
9. Accepted Insurance List
10. What is a FAANT-astic Visit?
11. Grapevine Area Map
12. Keller Area Map

Patient Guide to Portal

All patients should complete the first 5 pages: 1. Registration, 2. Consent, 3. Policies, 4. Past History, 5. Current History. In addition Medicare patients should also complete page 6, the Medicare Screening for Coordination of Benefits. And anyone under 18 should have their guardian complete, page 7, the Minor Authorization form.  

The requested forms should then be submitted to our office 48 hours prior to your appointment via our secure fax at 817-886-3612, or via the patient portal. This will help us update your record and expedite your visit.  
Please call our office if you have any questions regarding the a secure portal login or if need the Spanish version of these forms at 817-416-6155.