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830-627-2700

Pending New Patient Questionnaire

Complete this brief form before your visit

Why do you need to be seen? *

Select at least one option

Physical/Well child New Baby Sick visit Medication refill Establish Care

Please select at least one reason for visit

Patient Information

Patient Name This field is required

Gender (M / F)

Male Female

Please select gender

Date of Birth This field is required

Address This field is required

City This field is required

Zip This field is required

1st Contact Phone This field is required

2nd Contact Phone

Enter "NA" if not applicable

This field is required

Email Address Valid email required

Do we see any other family members? If yes, who?

Enter "NA" if not applicable

This field is required

Please list any chronic medical conditions or diagnoses that you have:

Enter "None" if not applicable

This field is required

Please list any medications that you are currently taking:

Enter "None" if not applicable

This field is required

Previous treating Physician & Reason for leaving:

Enter "NA" if not applicable

This field is required

Immunization Concerns

Please note we are a vaccinating clinic – we do NOT accept unvaccinated children.

Are you opposed to your child receiving the CDC recommended immunizations?

YES NO N/A (Adult patient)

Please select an option

Physician Assistant – Nurse Practitioners

Please note our mid-levels see our adult panel and same day sick appointments, as Dr. Boecker sees the newborns and infants. This practice does employ PA's and NP's.

As a patient, are you opposed to seeing a mid-level provider for any or all medical conditions?

YES NO

Please select an option

Insurance Information

I am self-pay / do not have insurance

Check this box to automatically fill insurance fields as not applicable

Insurance Company

Enter "Self-pay" if paying out of pocket

This field is required

Group #

Enter "NA" if not applicable

This field is required

Member ID#

Enter "NA" if not applicable

This field is required

Insurance Phone #

Enter "NA" if not applicable

This field is required

Claims Mailing Address

Enter "NA" if not applicable

This field is required

Policy Holder's name This field is required

DOB This field is required

SSN# This field is required

Relationship to patient This field is required

Address (if different from pt)

Enter "Same as patient" if applicable

This field is required

Secondary Insurance?

YES NO

Please select an option

If yes, then please list

Enter "NA" if no secondary insurance

This field is required

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Thank You!

Your questionnaire has been submitted successfully.

Our staff will review your information and contact you shortly.

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948 Gruene Road, #140, New Braunfels, TX 78130 | 830-627-2700

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