Child 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!

Contact Information (Parent/Guardian)


of Parent/Guardian


of Parent/Guardian






 




 








 



 
Employer Information




 
Parent - Insurance Provider


If "Yes" is selected all information below is required



as on insurance card



as on insurance card


as on insurance card


often on back of card



often on back of card

If you have secondary insurance complete the fields below



as on insurance card



as on insurance card


as on insurance card


often on back of card


often on back of card

 


Required if child is covered under parent's insurance provider


Other Parent - Contact Information




 



 




 




 




 





Child Information





of Child

 

Contact Us

Patient Information






 

ADD ADHD Treatment Center

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