Access2Health PLLC
Family Medical Group

New Patient Registration 1 year old and up only.

We are accepting new patients! No patients under 1 year old without prior approval by the provider.

Please complete registration below.  Once we receive your information we will call, text, or email you to schedule an
appointment during normal business hours. Please leave correct information for us to contact you and reply to our

We do take most forms of insurance and cash payments. We are a direct-pay provide and we can see anyone
regardless of whether they have insurance or not.

If you have questions or need to send us additional information, please give us a call at 409-241-7515, 1-888-887-0401
or us Email at

Don't want to use the form below?  Go here to download forms. >>>> Registration Form

New Patient Check-In/Registration Sheet (complete separate form for each patient)

Full Legal Name: *  
Nickname/Preferred Name:  

Gender (M, F): *  

E-mail address: *  

Home Phone: *  

Mobile Phone: *

Preferred method of communication (home phone, mobile, email) *  

Date of Birth: *  

We do not see patients under one year old at this time. If minor, under 18y/o (1-17) what are the names of parents or
guardians that will accompany you?: *  

Full address: *  

In case of emergency whom should we contact (name, relationship, phone)?: *  

With whom may we discuss your personal medical information (name, relationship)?: *  

Brief description of the reason for your visit to the clinic / Additional comments or information. *  
Note: Fields marked with * are required   
For Patient Use Only - No Solicitors Please
Please Note!!!
The forms
provided on this site
are for our
patient use only. No Sales
reps. Please
respect our privacy.
Reach us at 1-409-241-7515
Call / Fax us toll free at 1-888-887-0401
1050 S. 11TH St. Beaumont,Texas 77701