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Patient Application

 

DOB:



 

Emergency Contact                                                             

                                                                   




Primary Insurance Information





                                                  







Employer Information:

                                                 

Phone:




Check In:
• Please arrive 15 minutes before your appointment.
• Insurance cards should be given to the receptionist for every visit.
• Co-pay is expected at the time of service.
• Please bring all your medications/current medication list.
• One person may accompany patient in the exam room
• Please turn off cell phones.

Walk-in patients:
• Walk-in patients will be accommodated in between scheduled
appointments to be seen by their regular doctor if possible. Otherwise,
they will be seen by the doctor who has openings.

Missed Appointments:
• If you are unable to come for an appointment, please call us in
advance to reschedule.

Refills:
• Please contact us one week in advance. We do not call the
pharmacy for refills in the week-ends.

Sample Medicine/Letters/Forms:
• Please visit us/call us between 5-6 pm.

Patient Assistance Program:
• For patients without prescription coverage, we may be able to help
through the Patient Assistance Program. For further details, please visit us
Wednesday afternoons between 2-5pm.

Continuity of Care:
• We provide continuity of care for our patients during hospitalization.
One of our doctors will make rounds in the hospital.
• We also see our patients in the nursing homes.
• Our doctors can be reached for emergencies during the nights and
week-ends through the answering service. Please call the office number
and your call will be forwarded to the answering service. The doctor on
call will return your call.

 

 

© 2009 VIMA. All Rights Reserved

2121 E. Griffin Pkwy., Ste. 10 Mission, TX 78572 • (956) 583-7393

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