AmarilloMD New Patient Application/Registration
Please fill out this short survey to see if you are a good fit for our practice.
First and Last Name:
*
Phone:
*
Email:
*
Does the monthly membership fit into your family's budget?
*
Yes
No
Do you have a steady source of income?
*
Yes
No
Are you aware that an adult must register with us and become a patient in order for a child to have care with us?
*
Yes
No
Are you ready for personalized care and a relationship with your doctor?
*
Yes
No
Are you aware of how we are saving our patients large amounts of money by not billing insurance companies?
*
Yes
No
