Becoming a patient of Dr. Gazda

If you are interested in becoming a patient at Gazda Integrative Neurology, please complete the new patient inquiry form below and we’ll be in touch shortly. You may also contact us at (210) 853-3967 to speak with a staff member. Please do not send any personally identifying information or details specific to your health or current prescriptions via this form.

You may complete the form online below, print and return to us by email or regular mail – feel free to contact us to have this or any other forms sent to you by postal mail. Just let us know how we can best help!

Preliminary New Patient Form

* Indicates required field

Name *

First

Last

Address *

City *

Zip *

Phone Number(s) *

Email *

Are you the *

Patient Family member Authorized caregiver/guardian Other (please explain below)

Nearest relative with permission to contact *

Patient date of birth *

Primary care physician *

Medicare Eligible? *

Yes No

How did you hear about Dr. Gazda? *

Reason for contacting us *

Submit

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Downloadable Patient Forms

Gazda New patient Intake Form.pdf
File Size:	2730 kb
File Type:	pdf

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Becoming a patient

Preliminary New Patient Form

Downloadable Patient Forms

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