New Patients

Patient Information

Requested Appointment Date

First Name

Last Name

Home Phone

Cell Phone

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Past contact with TIC

Hospital/When

Referred By

Previous PCP

Primary Insurance

Policy #

Group #

Insurance Provider Phone

Subscriber's Name

Subscriber's Date of Birth

Effective Date of Coverage

Secondary Insurance Company

Secondary Policy #

Secondary Group #

Secondary Insurance Provider Phone

Subscriber's Name

Subscriber's Date of Birth

Effective Date of Coverage

Reason for Visit

Any recent hospital visits?

YOUR APPOINTMENT IS NOT CONFIRMED UNTIL YOU HAVE BEEN CONTACTED BY ONE OF THE AUTHORIZED REPRESENTATIVES TO TEXAS INPATIENT CONSULTANTS