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Phone:(512) 887-3955

HOURS: Mon - Fri, 9am - 5pm


New Member Enrollment

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Member Personal Information

Contact Information & Communications


Parent or Guardian

Primary person for discussing child's health information?

Member Portal

Please create a username and password that you will use to log into the portal in the future.

Your username must be at least 4 characters long and must be unique within the system (multiple family members must each have a unique username, though they may share one email address)

Your password must be at least 8 characters long and include at least one number or special character.

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

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.

Allergies

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

[x]
[x]

Children (Age 12 and Under)

Growth & Development:

Birth (Gestational) Term:

Current diet:

PREVENTION & WELLNESS

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)
Stroke
Colon Cancer
Breast Cancer
Ovarian Cancer
Prostate Cancer
Mental Health Issues
Birth Defect or Genetic Disorder
Growth or Developmental Delay
Asthma or Allergies
Alcoholism
Arthritis
Alzheimer's
Bleeding
Migraine
Thyroid Disease
Obesity

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.

[x]
[x]

HEALTH INSURANCE & INCOME

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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