NEW PATIENT FORM
    NEW PATIENT

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    MEDICAL HISTORY

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    download

    Spanish
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    NEW PATIENT FORM
    HIPAA FORM

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    Spanish
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    CONSENT TO TREAT

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    Patient Check-In Forms

    Our goal is to better serve you and improve your health! By completing the check-in forms ahead of time, you’ll save time in your appointment AND allow us to have the most accurate information. Please follow the instructions below:

    Download, Complete the Form, Scan/Save & Upload

    Steps:

    1)  Download the forms by clicking ‘download’ under the Form tab,

    2)  Print out and complete form,

    3)  Scan, save to your computer, and use the upload form to send us your information.

    NEW PATIENT FORM
    NEW PATIENT
    English
    download

    Spanish
    download

    NEW PATIENT FORM
    MEDICAL HISTORY

    English
    download

    Spanish
    download

    NEW PATIENT FORM
    HIPAA FORM

    English
    download

    Spanish
    download

    NEW PATIENT FORM
    CONSENT TO TREAT

    English
    download

    Spanish
    download

    Patient Check-In Upload Tool

    All patient information will be uploaded in an encrypted data format for security and confidentiality purposes. You may use this upload tool AFTER: 1) You have downloaded/completed on your computer and saved to pdf format OR, 2) You downloaded, printed and completed the Patient Check-In forms by hand and scanned the handwritten forms into a pdf format.

    "*" indicates required fields

    Name*
    MM slash DD slash YYYY
    mm/dd/yyyy
    Select and Attach:
    Drop files here or
    Accepted file types: pdf, Max. file size: 5 MB, Max. files: 5.
      Only .pdf files accepted

      SENDING & REQUESTING INFORMATION

      In a doctor/patient relationship, there may be more information that we need to obtain. Click on this resource list to send us Outside Lab Results, Imaging from other Providers, Medical Records from other Providers, or your personal blood sugar logs. Files must be in PDF, .doc, or .txt file formats.

      Trusted by Patients

      Dr. Carlos Arauz Pacheco, MD

      Learn More About Dr. Arauz-Pacheco's Biography, Specialities, and Certifications

      Dr. Carlos Arauz-Pacheco, MD is an Endocrinologist who has practiced in the Dallas area since 1994. He has expertise in several areas such as Diabetes Mellitus, Type 1 and Type 2, Hyperlipidemia, Obesity, diseases of the Thyroid Gland, Adrenal Glands and Pituitary Gland, Polycystic Ovary Syndrome, Parathyroid Disease, and Osteoporosis. He has ample experience in the management of Insulin Pumps, Thyroid Ultrasound, Thyroid Biopsies, among others.

      Dr. Dan Lender, MD

      Learn More About Dr. Lender's Biography, Specialities, and Certifications

      Dr. Dan Lender, MD is a Endocrinology, Diabetes & Metabolism Specialist in Rockwall, Texas with over 35 years of experience in the medical field.

      Learn More About Pauline Pagel's Biography, Specialities, and Certifications

      Polly has been a Registered Nurse for 30 years with experience in Emergency Room Nursing and Intensive Care Nursing at Parkland Hospital in Dallas.

      Dallas

      12606 Greenville Ave, #215
      Dallas TX 75243

      Hours: Mon-Thu 8:00 am-5:00 pm
      Fri: 8:00 am-Noon

      (214) 257-7721
      (972) 475-5668 fax

      Rockwall

      890 Rockwall Pkwy, #102
      Rockwall TX 75032

      Hours: Mon-Thu 8:00 am-5:00 pm
      Fri: 8:00 am-noon

      (972) 475-5600
      (972) 475-5668 fax

       

      info@diabetesendotx.com