New Patient Form
After you fill out these forms someone will contact you within 24-48 hours. Please DO NOT call the office to schedule an appointment as this will delay the process. Thank you.
If you need to cancel an appointment and it is not cancelled 24 hours in advance, regardless of the reason, you will be charged for the missed appointment. Please call our office at 832-982-1732 at least 24 hrs. in advance if you need to cancel a scheduled appointment.
Patient Demographics
All Fields Marked with * are Required. Page 1 out of 10.
Please Bring Your Lab and Diagnostic Results with You at the Time of Your Visit.
Page 1 out of 10
Which Doctor Would You Like to See? (Choose One)
Name (First Name, Middle Name, Last Name)
Prefer to be Called
Street Address
City
State
ZIP
Mailing Address
Is your Mailing Address Different From Your Street Address?
Street/PO Address
City
State
State
ZIP
More Informations
Home Phone
Work Phone
Fax
Cell
Preferred Method of Contact?
Marital Status
Gender
Birth Date
Age
Ethnicity
Race
Language
Employer
Occupation
Please select All that Apply
Reason You are Seeing a Doctor Today
Parent, Spouse, or Domestic Partner Information
Would You Like to Provide Parent, Spousal, or Domestic Partner Information?
Name (First, Middle, Last)
Home Phone
Work Phone
Cell
Birth Date
Gender
Employer
Occupation
Additional Questions
Do you have a Primary Care Physician?
Who is your Primary Care Physician?
Primary Care Physician Phone #
Were you referred to us by a Physician?
Who is your Referring Physician
Referring Physician phone#
Do you have a preferred pharmacy?
Do you have a Preferred Pharmacy?
Preferred Pharmacy Phone #
Pharmacy Location (Street/City)
Additional Information
Name of nearest relative not living with you
Phone
Someone we can leave a message with
Phone
Page 2 out of 10
Name
Please name someone we can talk with about your treatment and your relationship to them.
Phone #
Do you have an Advance Directive or POLST on file?
Do you have insurance?
CONSENT AND ASSIGNMENT OF BENEFITS I give consent to Neurology Consultants of Houston, P.A. to bill my insurance company and I give consent to release medical information for the purpose of treatment, payment and health care operations. I request that payment of Insurance benefits be made directly to Neurology Consultants of Houston, P.A. This consent is valid until revoked in writing. I understand I am ultimately responsible for payment for services rendered. I understand patients are responsible for obtaining any referrals or prior authorization that may be required by my insurance plan for this visit or future office visits and/or tests, as well as using Insurance-approved facilities for any outside tests ordered by Neurology Consultants of Houston, P.A.
Signature of Patient/Responsible Party Please upload your sign written with mouse, touch screen, or touchpad.
Max. size: 100.0 MB
Date
Call Us to Make an Appointment
Phone: 713-589-7020
Fax: 713-588-8980
3301 Plainview St, Suite 8
Pasadena, Texas 77504