11901 W Parmer Lane, Suite 310

Cedar Park, Texas 78613

(512) 528-9498

New Patient Request Form

Name *

Phone *

Email *

Address

Street Address *

City *

State *

Postal code *

Date of birth *

Behavioral Health Insurance Provider (at times this is separate from your major medical insurance provider and can be found on the back of your insurance card).

Feel free to upload your insurance card (front & back) here, or enter the information below

Download information here...

Insurnace Card Information:

ID Number
Group Number
Provider Contact Number

Have you been hospitalized for any psychiatric reasons in the past 5 years?

Are you applying for disability of FMLA?

Have you had any suicide attempts in the past 5 years?

Please be aware that we have a 3-business day cancelation Policy. If you need to cancel or reschedule any current appointment we ask that you call at least 3 business days in advance to allow us to offer that appointment time to another patient. If you miss / reschedule with less than a 3-business day notice you are subject to a cancelation fee of $100 for the initial appointment, and $50 for follow-up appointments. appointments *

Dr Earthman requires you complete a Medical/Psychiatric History Form prior to your Initial New Patient appointment with him. If you cannot complete the form online, we ask to you arrive at least 30 minutes prior to your scheduled appointment time appointment to complete it. Dr Earthman will not be able to see you without a completed form and you will be subject to a cancelation/reschedule fee. *

I consent to Dr Earthman reviewing my prescription medication history online prior to my first appointment. *

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