Pre-Registration

To request an appointment with Texas Neurology, please complete the form below. If you are a new patient, you will need to complete our New Patient Packet and bring with you on the day of your appointment. We also require access to your medical records prior to your appointment. This should include all records from the last 2 years and/or any pertinent medical records related to your upcoming visit. Having access to your medical records prior to your appointment is required and will provide us with the necessary information for your appointment. If you are an existing patient and need immediate assistance, please call our scheduling department at (214) 827-3610 and select option 3.

Visit Type










Patient Information

First Name*

Last Name*

Middle Initial

Date of Birth *

Gender*

Address*

City*

State*

Zip*

Email*

Phone (Home)

Phone (Work)

Phone (Mobile)

Primary Insurance Coverage

Carrier

Phone Number for Providers

ID #

Group #

Name of Insured

Date of Birth for Insured

Secondary Insurance Coverage

Carrier

ID #

Group #

Name of Insured

Date of Birth for Insured

Appointment Details

Provider Preference

Time Preference

Day Preference

Number Preference

Reason for Appointment

Additional Comments

Medical Records/Correspondence

Is there a physician you would like our Texas Neurology physician to correspond with after your appointment? If so, please provide their name, address, and phone number.

Name

Address

City

State

Zip

Phone

Fax