Southlake Neurology and Neurophysiology Clinic, PLLC

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         New Patient .pdf forms (all three (1-3) forms must be filled out). These forms require Adobe pdf reader-- download 

  1. Privacy Questionnaire
  2. Consent to Treat
  3. New Patient Demographics
    4. Privacy Note  (For your information only)

     

    Record release forms

    • Record Release Form (to Southlake Neurology)
    • Record Release Form (from Southlake Neurology)

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        Notice to all patients
      • New patients please bring you list of medications, copies of records,  and any imaging studies/films you may have.
      • Copays and deductibles are due at the time of service
      • Cancellation fees of $25 may apply if the office is not notified of cancellation within 12 hours of appointment
      • All disability and insurance forms filled out by physician are subject to a charge of $25