New Client Registration
PLEASE NOTE: WE TRY OUR BEST TO ACCOMMODATE YOU. REGISTRATION IS NO GUARANTEE OF AN APPOINTMENT AS AVAILABILITY FLUCTUATES ON A DAY-TO-DAY BASIS.

If you are interested in becoming a new patient please submit the following form to our office to begin the process. It is our desire to ensure a proper fit between our practitioners and you; the following information will help us in doing so. Please be aware that there are limitations on who can be seen in our office. Requests for new patient consultations are reviewed and may take a week or more to process during our busy periods. We ask that you please be patient and do not submit multiple requests as this will only delay our efforts to make appropriate contact with all of those waiting.

Thank you for your interest in PsychiatryAustin!

**This form is encrypted and stored in a HIPAA compliant database.**
**This form takes 5-10 minutes to complete. You will need your insurance information and a payment method.
Your First and Last Name *
Email Address *
Primary Contact Phone *
Address *
City
State *
Zip *
Patient First and Last Name *
Gender *
Date of Birth *
Age *
How did you hear about us? *
Before We Gather Your Clinical Information Please Initial The Following Agreement:
AGREEMENT
I understand by initialing below that due to state legislation (Health and Safety Code Title 6; Subtitle C; Chapter 481.001- 481.354) stimulant use has been made highly restrictive by Texas legislature. Your initials below demonstrate your understanding that in order to have your current prescription be renewed it would require at least one of the following: 1) a clear photograph of your current med bottle (or bring the bottle in itself) 2) a current log from your pharmacy 3) a current note from your prescribing physician or the medical records that indicate that this is part of your regimen *
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