Online Form Step 1 of 4 25% NameThis field is for validation purposes and should be left unchanged.Patient InformationName (Last, First, Middle)(Required)MaidenAddressCityStateZipDOBDriver's License#Phone(Required)Email(Required) OccupationEmployerMarital Status Married Single Divorced Widowed Spouse (Last, First, Middle)MaidenEmergency ContactRelationshipEmergency Contact PhoneIf the Patient is a minor (under the age of 18) or incapacitated, please provide information of the parent or legal guardian.Parent or Legal Guardian NamePhone Insurance InformationInsurance CompanyID#PlanGroup#Policy Holder’s NameRelationship to PatientPolicy Holder’s DOBPolicy Holder’s EmployerPrimary Care PhysicianPCP PhonePreferred PharmacyPharmacy Phone Medical HistoryReason for VisitReferring Physician(Required)Please List Any Current or Past Medical Problems and Approximate DatesPlease List All Current Medications, Dosage, and DurationPlease List Any Allergies to MedicationsPlease List Any Major Surgeries and Approximate DatesPlease List Any Family History of Major Current or Past Medical ProblemsDo you drink alcohol?(Required) Yes No If so, how oftenDo you smoke cigarettes?(Required) Yes No If so, how oftenDo you take prescription drugs for non-medical reasons?(Required) Yes No Do you take illegal drugs?(Required) Yes No AUTHORIZATIONI certify that the above information is true and accurate. I authorize the release of any medical or other information necessary to process a claim or continue medical treatment. I also authorize payment of medical benefits paid directly to Texas IR and Interventional Oncology. I acknowledge that I am responsible for payment if my insurance company denies my claim.Patient Name(Required)Date(Required)Parent or Legal Guardian (If patient is a minor or incapacitated)Date
