Alice Form – Elizondo Medical Group

Patient Information

Last Name(Required)

First Name(Required)

Date of Birth:(Required)

Home Phone:(Required)

Work/Cell:

Preferred Provider:(Required)

Age:

Patient Information (We are not taking any New Patient's with any Medicaid plans)

Home Address:(Required)

City/State/Zip:(Required)

SS#(Required)

Sex:(Required)

Male

Female

Transgender

Previous Dr.

E-mail Address: (for Patient Portal)(Required)

Preferred Language:(mark if Spanish Only and put note on reason to inform MA/Provider)(Required)

English

Spanish

Sign Language

Other

Medical Insurance

Primary Insurance Name:(Required)

Policy Number:(Required)

Group #:

Responsible Party:

Self

Spouse

If Spouse is insured, name of Spouse:

Secondary Insurance Name:

Policy Number:

Group #:

Responsible Party:

Self

Spouse

Chronic Conditions

Are you currently taking any medication for Pain?(Required)

Yes

If Yes, pain location?(Required)

**Rx name, if answered yes(Required)

mg(Required)

qty per day(Required)

Are you currently taking any medication for Anxiety?(Required)

Yes

**Rx name, if answered yes(Required)

mg(Required)

qty per day(Required)

Are you currently taking any medication for Depression?(Required)

Yes

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

Are you currently taking any medication for Attention Deficit Disorder?(Required)

Yes

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

Are you currently taking any medication for Drug Withdrawal?(Required)

Yes

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

Preferred Provider:(Required)

Patient Signature:(Required)

Date:

EMG’s acceptance of you as a patient of our practice is subject to your accurate completion and submission of this form and our verification of any information you provide that we believe is relevant, as well as being subject to our review of the Texas Prescription Monitoring Program (TPMP) database, as Texas law requires our prescribers to first access TPMP prior to our prescribing certain medications to patients, and you hereby acknowledge our policy and terms set forth herein regarding accepting new patients. Your completion and submission of this form to us does not itself establish you as a patient of our practice.

By submitting this form you acknowledge the above statement.

Elizondo Medical Group New Patient Inquiry

Patient Information

Patient Information (We are not taking any New Patient's with any Medicaid plans)

Medical Insurance

Chronic Conditions