The Urology Team - Urology Doctors Located in Austin, Texas

New Patient Registration

Online Registration Form

DEAR PATIENT: We have made every attempt to reduce the amount of paperwork that you need to fill out and also make the process more efficient. Your cooperation and correct completion of the information below will assist us in obtaining the information correctly the first time. Please provide a copy of your primary and secondary (if applicable) insurance card to the front desk. THANK YOU!

Is your condition a result of a work injury?

Or related to an auto accident?

PATIENT INFORMATION

Last Name:

First Name:

MI:

Address:

City:

State:

Zip:

Phone:

Cell:

E-mail:

DOB:

Age:

Sex:

Marital Status:

Employer:

Occupation:

Work Address:

City:

State:

Zip:

Work Phone:

E-mail:

Emergency Contact:

Phone:

Cell:

Patient relationship to primary cardholder:

If you are not the primary cardholder please complete next box.

PRIMARY AND SECONDARY CARDHOLDER INFORMATION: Please complete this section if the patient is not the primary cardholder for their primary and secondary insurance. This information is REQUIRED BY YOUR insurance company for identification of policyholder and correct billing.

Cardholder's Name:		Cardholder's Occupation:
Cardholder's Employer:		Cardholder's work #:
		Cardholder's DOB:

INSURANCE INFORMATION: Please complete in its entirety. All fields are needed to file to your insurance company. Please remember to bring your insurance card with you.

PRIMARY

SECONDARY

Insurance Company:		Insurance Company:
Policy Holder:		Policy Holder:
Policy - ID Number:		Policy - ID Number:
Group Number:		Group Number:
Customer Service Phone:		Customer Service Phone:

PATIENT REFERRAL INFORMATION: Your insurance company and Urology Team REQUIRE this information. The Urology Team MD utilizes this information to send communication about your care to your referring and primary care physician (if appropriate).

Referring MD (full name):		Phone #:
Primary care physician:		Phone #:

SCHEDULE YOUR FIRST APPOINTMENT: If you would like to schedule an appointment with Urology Team, use this convenient NON-URGENT online form. The date and time requested will be secured ONLY upon confirmation from our scheduler. Your appointment will be confirmed within the next 24 hours. Please call us if you do not hear from us. COMPLETE ALL information in order to process your request.

First Choice:

Second Choice:

Reason for the Appointment:
Is there anything you'd like us to know before you arrive?

How did you hear about us?

Name of Friend:

Name of Doctor:

After submitting, you will be sent to more forms which need to be filled out and brought to our office for your first visit.

11410 Jollyville Road, Austin, Texas 78759
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