Before your first visit

New patient intake

Share a few details ahead of time so your first appointment can be spent on care, not paperwork. This form is for adults 18 and older.

A little preparation

Start with what feels useful.

Tell us what you would like help with and share the health details that can help us prepare. It is okay to leave optional questions blank.

Need help?

(832) 371-6133

For emergencies, call 911 or go to the nearest emergency room. This form is not monitored for urgent medical concerns.

1. About you

First name

Last name

Date of birth

Phone number

Preferred contact method

Preferred language (optional)

2. Address (optional)

Street address (optional)

City (optional)

State (optional)

ZIP (optional)

3. Visit details

Reason for your visit / what you’d like help with

Primary care goal or conditions you’re managing (optional)

How did you hear about us? (optional)

4. Health background (all optional)

Current medications (optional)

Allergies (optional)

Past medical history or surgeries (optional)

Preferred pharmacy name and location (optional)

5. Insurance

Do you have insurance? (optional)

Insurance provider (optional)

Member ID (optional)

6. Acknowledgements

I agree to receive text messages from BellNow Virtual Care, including appointment reminders and care-related updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not a condition of receiving care.

I understand this form is not for emergencies and that I should call 911 or go to the nearest emergency room for urgent medical concerns.

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New patient intake

Start with what feels useful.

Thank you — we've received your intake form.