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Phone:(512) 887-3955

HOURS: Mon - Fri, 9am - 5pm

New Member Enrollment: Company Account Member

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Member Personal Information


Contact Information & Communications

To access our Member Portal (patient records, etc.) each member will require a unique email address. Family members cannot share the same email address for this function. However, you can learn how to create multiple "alias" email address under your primary care account here.

Parent or Guardian

Primary person for discussing child's health information?

Member Portal

To gain online access to your medical records and secure communications, please create a password containing at least 8 characters and 1 number or special character.

Authorization to Use Email, Text & Internet Services

Alternate Contact Person

Used in case of emergency or inability to contact primary person.

Authorization to Discuss Health Information

Other designated people we may discuss your medical information with:

Level of Education

Health History

This health information is used only for our medical purposes and will not be shared with any third-parties without your permission. We do NOT use health status to determine fees or deny membership.


Do you have any allergies to: drugs, latex, iodine, or other medical supplies? *

Current Medications

Please include any and all medications you have taken in the past 6 months, including those you have finished, take "as needed", supplements, vitamins, etc.

If you are taking any of the below medications, please review our MEDICATION POLICIES to make sure Euphora Health is right for you. 
  • Amphetamines (Ritalin, Adderall, Phentermine, etc.)
  • Opiates (Morphine, Hydrocodone, Lortab, Codeine, etc.)
  • Benzodiazepines (Lorazepam, Valium, Xanax, etc.)
  • Sleeping Medications (Ambien, Lunesta, etc.)

General Health

Ongoing or Chronic Medical Problems

Previous Surgeries or Procedures

Previous Significant Events

Issues that are now resolved or not active


Children (Age 12 and Under)

Growth & Development:

Birth (Gestational) Term:

Current diet:


Be as accurate as possible. If never, leave blank

Childhood immunizations?

Year of Most Recent Tetanus Shot (TD)?

Colon Cancer Screening

Women's Health

Birth Control Methods

    Yes | No
    Yes | No
    Yes | No

Men's Health

Prostate Cancer Screening?

    Yes | No

Travel History

Yes No
Yes No
Yes No

Family History

  Father Mother Brother Sister Child
High Blood Pressure
High Cholesterol
Diabetes, Type 2
Heart Attack
Sudden Cardiac Arrest (unexplained)
Colon Cancer
Breast Cancer
Ovarian Cancer
Prostate Cancer
Mental Health Issues
Birth Defect or Genetic Disorder
Growth or Developmental Delay
Asthma or Allergies
Thyroid Disease

Other Health Care Providers

Include ALL doctors or health care providers (or their medical practices) you have seen in the past 1 year - even if you do not intend to see them again.



Insurance Information

Euphora Health does NOT contract with or accept payment from any health plans. However, we can provide you with a receipt that has insurance codes included.

If you have insurance, what type(s)?

We currently cannot accept patients that are enrolled in any Medicare or Medicare Advantage health plans.

Current Health Plan Through Employer?

Household Income

Used for informational purposes only. Does not effect membership eligibility or pricing.

What is the reason you chose Euphora Health as your medical clinic?

Current Medical Issues

How did you hear about Euphora Health?

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