Jeri Penkava | New Patient Forms
16390
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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!