Timothy N. Gorski,  M.D., F.A.C.O.G.
1001 North Waldrop, Suite 815
Arlington, Texas  76120
(817) 792-2000

Please complete this form so that we may prepare or update your chart.  This information is needed for identification purposes and to help us contact you when necessary.  Please give ALL information requested.  We appreciate you time.

Last Name: ________________________________________ First: ______________________________ Middle Initial: ________

Address: ____________________________________ City: ____________________________ State: _________ Zip: ___________

Home Phone #: ___________________________ Work Phone #: __________________________ Marital Status:   S   M   D   W    

Drivers License #: ___________________________ Social Security #: ______________________ Date of Birth: _____________

Employer: ___________________________ Address: _______________________________ Position: _______________________

Name of Spouse: ___________________________ Employer: _____________________ Work Phone #: ____________________

Drivers License #: ___________________________ Social Security #: ______________________ Date of Birth:______________

Nearest Relative: ____________________________________ Relation: _____________________ Phone #: __________________

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Primary Insurance: __________________________________________ Policy Holder: ___________________________________

Member I.D. #: _________________________ Group #: ________________ Member Services Phone #:____________________

Secondary Insurance: __________________________________________ Policy Holder: _________________________________

Member I.D. #: _________________________ Group #: ________________ Member Services Phone #:____________________

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Please Indicate How Much You…  Smoke? ______________ Drink? ______________ 

Do You Have a History of Drug Abuse? _________________________________________________________________________

Current Medications and Allergies:_____________________________________________________________________________

Pharmacy: _______________________________ Phone #: ___________________________ Location: ______________________

Primary Care Physician:_______________________________________________________________________________________

How were you referred to us? __________________________________________________________________________________

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I understand that I am responsible for ANY charges incurred on my account with Timothy Gorski, M.D., and I agree that payment in full will be made for services rendered.  If patient is a minor, I certify that I am the legal guardian or responsible party.

Signed: _____________________________________________________________________________ Date: __________________