Kingsville Form – Elizondo Medical Group

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Elizondo Medical Group New Patient Inquiry

For immediate assistance or quick questions, please call (361) 355-9700 or complete the form below and a member of our team will contact you promptly.

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

No

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

No

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

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

Yes

No

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

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

Yes

No

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

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

Yes

No

**Rx name if answered yes(Required)

mg(Required)

qty per day(Required)

Preferred Provider:(Required)

Patient Signature:(Required)

Date:

MM slash DD slash YYYY

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.

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.

(Required)

By submitting this form you acknowledge the above statement.

© 2026 Elizondo Medical Group.