2840 Legacy Drive, Suite 300, Frisco, TX 75034-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the 'Patient Information Sheet' section. Fill in your name, social security number, and date of birth accurately.
3. Next, provide your address details including street address, city, state, and zip code. Ensure that all phone numbers are entered correctly for effective communication.
4. Complete the 'Spouse Information' section if applicable. Include their name, social security number, and contact details.
5. Fill out the 'Emergency Contact Information' with a reliable contact's name and phone number for emergencies.
6. Proceed to the 'Insurance Information' section. Enter your insurance company details and primary insured's name as required.
7. Review the authorization checkboxes carefully. Check each box that applies to you regarding insurance information and consent for treatment.
8. Finally, sign and date the form at the bottom to confirm that all information provided is accurate.

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