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.

  • Step 1
  • Step 2

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

Email

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

Talk to a Doctor Today

24/7 SERVICE. SAME DAY APPOINTMENT AVAILABLE.

Phone: 713-589-7020

Fax: 713-588-8980

3301 Plainview St, Suite 8

Pasadena, Texas 77504