New Patient Registration Form

  If you have not filled out an intake form and been accepted to the practice, please do that before filling out the form below.

**If you are filling out this form on behalf of an adult patient, please read our FAQ Page on Privacy 

Thanks for filling those out! Now wait from a call from us and we'll set up the first appointment.

Please note, it may take up to 24-48 hours for appointment requests to be confirmed so we ask your patience.

Forms to Review

Phone: 682-200-1744

Secure Fax: 682-478-5487


Main Office: 1001 12th Ave, Suite 174

Fort Worth, TX 76104

Southlake Office : 410 N Carroll Ave, Suite 190

Southlake, TX 76092