Become a patient

Please fill out the form below or use Adobe Reader to open and print.
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You may fax or mail to our office.
Tyler Internal Medicine 1910 Roseland Blvd. Tyler, TX 75701 FAX (903)533-0441

Please send a copy of your current insurance card(s). Do not return via e-mail due to privacy policies.

New Patient Questionnaire

All fields are required.

Full name

Gender

Date of birth

SSN #

Email address

Postal address

Home phone number

Work phone number

Cell phone number

Policy holder name

Insurance plan name

Secondary insurance plan name

Insurance group number

Verify benefits phone

Member # on card

Current medical problems

If you have nothing to note, leave the box blank.

Current medications

If you have nothing to note, leave the box blank.

Current physician

Do you have any history of TB?

Do you currently have a work or Motor Vehicle Accident (MVA) related injury or illness?

Preferred physician

Where did you hear about us?

Electronic signature

Tyler Internal Medicine requires that you certify your application by submitting an electronic signature. To certify your application, read the text below and provide an electronic signature (type your name) and click Submit. I certify that all the information within this form is accurate and true.

First name

Last name

We are accepting new patients

Electronic signature