Katy Appointment Request Form

Select Time:
MorningAfternoon

Demographics/insurance information :

First Name*:

Last Name*:

Are you a new patient?*:
 Yes No

Address*:

Email*:

Best contact number*:

Date of Birth (Enter in MM/DD/YYYY)*:

How did you hear about us?*:

If referred by a physician, please enter physician's name.

Who is your primary care doctor?*:

What is the address of your preferred pharmacy to pick up your medication?*:

Insurance Carrier:

Group:

Member ID:

Claims Address:

Reason for your visit*:

Height*:

Weight*:

Medical History:

Allergies (Please select all that apply)*:
 None Known Allergies
 Adhesive Tape
 Local Anesthetics
 Aspirin
 Penicillin
 Iodine / Shellfish
 Codeine
 Demerol
 Food Allergies
 Other

Please list 'Other' allergies:

Please list all medications you are currently taking. If none, enter NONE*:

Medical History - Please check all that apply*:
 None
 Blood pressure
 Circulatory Problems
 Diabetes
 Local anesthetic
 Other

Please list all Medical History you have. If none, enter NONE*:

If you are diabetic, what is your last hemoglobin A1C reading? (Enter N/A if not applicable)*:

Please list all major surgeries you've had in last 10 years. (If none, enter NONE.)*:

Have you had the flu shot this season?*:
YesNo

When was your last flu shot? If not applicable, enter NA*:

Pneumonia shot – If you are over 65, have you had a pneumonia shot?*:
YesNo

When was your last Pneumonia shot? (If not applicable, enter NA)*:

Are you currently smoking?*:
YesNo

What is your shoe size?*: