If submitting this form within 24 hours of your scheduled appointment, please print page and bring to your appointment.

Client Information

Name: ________________________________________________________

Street Address:____________________________________________________

City:________________________________ State: _______ Zip:______________

Phone:________________ Mobile: _____________ Pager: ______________

Emergency Contact:____________________________ Emergency #:_______________

Place of Employment:_____________________________ Work #:_______________

*Driver’s License:___________________ Date of Birth: _______________

*Social Security #:___________________________

*Required

PAYMENT IS EXPECTED AS SERVICES ARE RENDERED
We accept MasterCard, Visa, American Express, Care Credit, Cash, and Check (Checks only with Valid Texas Driver’s License)
We do not accept the Discover Card

Signature:_____________________________________

How did you become aware of our clinic?_____________________________________________