Jeri Penkava | New Patient Forms
16390
page-template-default,page,page-id-16390,_masterslider,_ms_version_3.8.1,ajax_fade,page_not_loaded,,paspartu_enabled,qode-theme-ver-11.0,qode-theme-bridge,wpb-js-composer js-comp-ver-5.4.5,vc_responsive

New Patient Forms

Please fill out the following contact form with patient information, main concerns and type of appointment you need (evaluation for new diagnosis, follow-up care for a previous diagnosis, integrative treatment, or neurofeedback therapy) contact phone number and email, and send a copy of your insurance card and a copy of your photo ID to:

adhdplus.records@att.net or fax to: 210-403-2350

    Patient Name*:
    Birth Month:
    Birth Day:
    Birth Year:
    Parent or Guardian:
    Phone*:
    Email*:
    Type of appointment requested:
    Current Insurance:
    Brief description of the medical, academic or behavior problem:

    We will contact you to advise on how to proceed for the full evaluation of you or your child. Thank you for your confidence in our office!