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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? *

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Please select at least one reason for visit

Patient Information

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Please select gender
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Valid email required
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Enter "None" if not applicable
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Immunization Concerns

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

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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.

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Insurance Information

Check this box to automatically fill insurance fields as not applicable
Enter "Self-pay" if paying out of pocket
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Enter "Same as patient" if applicable
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Enter "NA" if no secondary insurance
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Your questionnaire has been submitted successfully.

Our staff will review your information and contact you shortly.

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Important Notice

Gruene Lake Medical is currently only accepting new baby patients.

If you are filling out this form for a patient other than a new baby (infant), please be aware that we may not be able to accept this patient at this time.

By clicking "I Understand" below, you acknowledge this limitation and wish to proceed with the form submission.