Adult Application

Hello and Welcome!

Please take a moment to review and fill out the new patient application form below. Submitting this form prior to your first appointment will ensure your prompt attention upon arriving. Our goal is to provide you and your family with excellent medical treatment along with our friendly, courteous service. Thank you again for choosing our physician associates, for specialized and exceptional ADD/ADHD healthcare!

APPLICATION

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Employer Information




 
Insurance or Cash Pay?


If “Yes” is selected all information below is required





(As on insurance Card)

(As on insurance Card)





 

If you have Secondary insurance complete the fields below.



(As on insurance Card)

(As on insurance Card)

(As on insurance Card)



 

Contact Us

Patient Information






 

ADD ADHD Treatment Center

(972) 943-0410 | Fax: (972) 212-4270 | Email: [email protected]
1524 Independence Parkway Suite A-1 Plano, TX 75075

Connect with us!!

(972) 943-0410
1524 Independence Parkway Suite A-1Plano, TX 75075

[email protected]

Connect with us!!