NEW PATIENT FORM
    NEW PATIENT

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    Spanish
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    MEDICAL HISTORY

    English
    download

    Spanish
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    NEW PATIENT FORM
    HIPAA FORM

    English
    download

    Spanish
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    CONSENT TO TREAT

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    Spanish
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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.
    • MM slash DD slash YYYY
      mm/dd/yyyy
    • Drop files here or
      Accepted file types: pdf, doc, Max. file size: 10 MB, Max. files: 5.
        .pdf, .doc, .txt 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 is an endocrinologist in Rockwall, Texas and has been in practice for more than 20 years.

      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.

      Dr. Erin Dunnigan Roe, MD

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

      Erin D. Roe, MD, MBA, FACP is board certified in internal medicine and in endocrinology, diabetes and metabolism and has over 15 years of experience in the medical field.

      Learn More About Carlos Arauz's Biography, Specialities, and Certifications

      Carlos has worked as a physician intern in endocrinology and internal medicine, surgery, pediatrics, obstetrics & gynecology, and family/community medicine at the various public hospitals throughout Costa Rica as well as at Hennepin County Medical Center in Minnesota.

      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.

      Lori Kleinfield, RD, CDE

      Learn More About Lori's Biography, Specialities, and Certifications

      Lori is a Certified Diabetes Educator and Registered Dietitian who specializes in nutrition counseling. wellness, and diabetes education.

      Dallas

      12606 Greenville Ave, #215
      Dallas TX 75243

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

      (214) 660-2020

      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

      info@diabetesendotx.com