New Patient Information Form
Patient Name
*
First Name
Last Name
Patient Gender
*
Please Select
Male
Female
Patient Birth Date
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Patient E-Mail
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Preferred Phone
*
-
Area Code
Phone Number
Alternate Phone
-
Area Code
Phone Number
Insurance Information
Please provide accurate insurance information so that we may verify our providers are in network with your plan
Policy Holder
*
First Name
Last Name
Policy Holder Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Primary Insurance Plan Name
*
Medicare, BCBS, United Healthcare, etc.
Primary Insurance Member ID
*
Primary Insurance Group Number
Secondary Insurance Group Number
If no secondary insurance, leave blank
Secondary Insurance Plan Name
Secondary Insurance Member ID
Patient Medical History
Current Medical Problems/Reason for Seeing Doctor
*
List of Current Medications
*
If none, type n/a
Current Primary Care Physician
Or current specialist if you do not have a PCP
Do you have any history of TB?
*
Yes
No
Unsure
Do you currently have a work or Motor Vehicle Accident (MVA) related injury or illness?
*
Yes
No
Preferred TIMA Physician
*
No Preference
Dr. Branch
Dr. Buzbee
Dr. Davis (Lindale)
Dr. Peterson
Dr. Saurette
Dr. Simpson
Dr. Villena
Kelly Cox, FNP (Lindale)
Blaise Davis, FNP-C
Amy Vander-Vorste, NP-C
Melisia Martin, FNP-C
Chris Williams, PA-C
Slade Braswell APRN FNP-C
Where did you hear about TIMA?
Internet, friends & family, physician referral, etc
Electronic Signature
Tyler Internal Medicine Associates requires that you certify your information by submitting an electronic signature. Please ensure all information above is accurate and correct, then type your name in the below.
Electronic Signature
*
First Name
Last Name
Submit
Should be Empty: