1-713-771-2292

New Patient?

Please Complete
New Patient Registration Form

Documents for registration:

  • One form of identification with current address (Driver’s License, Passport, Green Card, etc.).
  • Insurance card (if applicable).
  • List of current medications, including vitamins.
  • Immunization record (if applicable).

For pediatric patients: If you are not the parent, please provide proof of legal guardianship.

Frequently Asked Questions

Patient Registration Forms: Select your language

English



    Please Check One of the Following:

    Hispanic origin:

    If Hispanic please check ethnicity:

    Have You Ever Used Another Name?




    Gender:

    Gender Identity:

    Sexual Orientation:

    Housing Status:








    Preferred Language:


    Marital Status:

    Are You A Veteran of The US Armed Forces?

    If The Child Is Under 18 and Receiving Vaccines Please Complete The Following:



    Is This Patient Covered By Insurance?

    If you checked “No” please skip this section.

    Please Indicate Primary Insurance:











    Patient’s Relationship To Subscriber:




    In Case of Emergency:








    Medical Power of Attorney:




    How Did You Hear About Us:







    Spanish



      Elija una de las siguientes opciones:

      Origen Hispano:

      Si es Hispano Especifique la Etnia:

      ¿Alguna vez ha usado otro nombre?




      Genero:

      Identidad de Género:

      Orientación Sexual:

      Estatus de Vivienda:








      Idioma Preferido:


      Estado Civil:

      ¿Es Veterano de las Fuerzas Armadas de Los Estados Unidos?

      Si el niño es menor de 18 Años y Recibirá Vacunas Responda lo Siguiente:



      ¿Tiene la paciente cobertura médica vigente?

      Indique la cobertura médica principal:











      Relación del Paciente con el Titular:




      En Caso de Emergencia:








      Poder Notarial Medico:




      ¿Cómo se enteró de nosotros?







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      Bee Busy Wellness Center

      8785 W Bellfort St
      Houston, TX 77031

      Office : +1 713-771-2292

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      Bee Busy Wellness Center receives HHS Funding and has Federal Public Health Services (PHS) deemed status with respect to certain health or health related claims, including medical malpractice claims, for itself and its covered individuals.