Make an Appointment

Please Choose Below The Appointment Type

Appointment Type

Existing Patient

Are You An Existing Patient?

Patient's Last Name*

Date of Birth*

age2

We apologize for the inconvenience and we only see patients 16 years of age or older.*

Phone Number*

Email*

Please enter if you have a new address*

Street Address

City*

State / Province / Region*

Zip/Postal Code*

My Insurance

Select Primary Insurance

Self-pay
Primary Insurance

Primary New Insurance

Other Insurance*

Primary Insurance ID #*

Primary Insurance Group #

Please upload if you have a new Insurance card

Please provide the front image of your insurance card

Please provide the back image of your insurance card

Please upload if you have an updated Driver's license

Please provide the front image of your Driver's License

Please provide the back image of your Driver's License

Secondary Insurance

Secondary Insurance ID #

Secondary Insurance Group #

Appointment Reason*

Other Reason*

Appointment Reason Description*

Appointment Preferred Date*

New Patient

Patient's Last name*

Last Name

Date of Birth*

age

We apologize for the inconvenience and we only see patients 16 years of age or older.*

Do you have an open legal case or court case? Workers Compensation or Child Protective Services (CPS) Hearing?

Yes
No

we apologize for the inconvenience, we do not specialize in these matters and we cannot make the appointment.

Are you already ON any pain-control-medication (like hydrocodone, Percocet, Tylenol w/codeine, pain controlling patches, or any opioids)? Please be advised that we will NOT be able to prescribe any benzodiazepines(example Xanax, Klonopin, Valium, Ativan)due ti DEA regulations.

Already On any pain-control-medication*

Yes
No

Please contact our Appointment Team at 817-488-8998 ext 2 to further assist you

I acknowledge that urine sample*

I Agree (Mandatory)

I acknowledge that urine sample will be asked for a Urine Drug Screen, either at the office of Mid Cities Psychiatry or through an accredited laboratory within 48 hours of Mid Cities Psychiatry’s request. If the Urine Drug Screen is (1) positive for substances not prescribed or (2) negative for medications prescribed by a provider engaged in your care and treatment, Mid Cities Psychiatry has the right to decline any further prescriptions.

I acknowledge that coming to appointment does not guarantee that control-medication*

I Agree (Mandatory)

I acknowledge that coming to appointment does not guarantee that control-medication will be prescribed. It’s up to the Provider’s discretion when they meet the patient.

RCN (Rescheduling / Cancellation / No-Shows) Policy:*

I agree (Mandatory)

An appointment Rescheduled or Canceled within 24 business hours of your appointment or No-Show at the appointment will be billed the full $75 cancellation/no show fee (so to avoid our billing company billing you $75, please call in more than 24 business hours).. Please be advised calls made 24 hours before the appointment on weekends or long-weekends or on National Holidays when our offices are closed are not 24 Business Hours.

My Contact Information

Phone Number*

Email*

Address*

Street Address

City*

State / Province / Region*

Zip/Postal Code*

My Insurance

Insurance

Self-pay
Primary Insurance

Primary Insurance*

Other Insurance*

Primary Insurance ID #*

Primary Insurance Group #

Please upload your Insurance card

Please provide the front image of your insurance card*

Please Provide the back image of your insurance card*

Please upload your Driver's License

Please provide the front image of your Driver's License*

Please provide the back image of your Driver's License*

Secondary Insurance

Secondary Insurance ID #

Secondary Insurance Group #

Appointment Reason

Appointment Reason*

Other Reason*

Appointment Reason Description*

Appointment Preferred Date & Time

Appointment Preferred Date*

Appointment Preferred Time*

8:00 AM - 12:00 PM
1:00 PM - 3:40 PM

How Did You Hear About Us*

Name of the Provider*

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Make an Appointment

Make An Appointment!

Existing Patient

My Insurance

Please upload if you have a new Insurance card

Please upload if you have an updated Driver's license

New Patient

My Contact Information

My Insurance

Please upload your Insurance card

Please upload your Driver's License

Appointment Reason

Appointment Preferred Date & Time