NTMC Complete Care | North Texas Medical Center

NTMC HEALTH SCHOOL-BASED TELEMEDICINE Enrollment form

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This field is for validation purposes and should be left unchanged.

Child's Name(Required)

First Middle Initial Last

Gender

Male

Female

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

What school does the child attend?(Required)

Parent / Guardian Name(Required)

First Middle Initial Last

Primary Phone Number(Required)

Email Address(Required)

Relationship to the Patient(Required)

Date of Birth(Required)

In the event I am unable to attend my child's visit, I give my permission for these individuals to participate on my child's telemedicine visit:

Name

Phone

Name

Phone

Please select the type of insurance for the patient(Required)

By signing below, I represent that I have the legal authority to consent to medical treatment for the patient listed above.

Signature(Required)

1902 Hospital Blvd.
Gainesville, TX 76240

Monday-Friday, 8 a.m. to 5 p.m.