Doctors Hospital at Renaissance - School Based Health Center

To make your registration with the ECISD School District as fast and easy as possible, please complete and submit the following scheduling request form.

This form shall only be utilized for scheduling visits to ECISD and shall, under no circumstance, be utilized for any emergency patient cases. In the event of an emergency patient case, please send the patient directly to the Emergency Room.

Please be sure to enter all scheduling information correctly. ECISD shall not be responsible for any delays in the registration process that may result from the incorrect submission of any information through this system.

Patients will still be required to personally present to ECISD personal identification and insurance information to fully register prior to their visit.

Please note that completion and submission of this form does not guarantee a visit at ECISD.

Patient information Please enter full legal name.
Last Name	First Name	Middle Name
Address	City	State Zip Code
County	Phone - -	Gender MaleFemale
Social Security Number	Date of Birth
Race	Primary Language Spoken

Patient information

Please enter full legal name.

Last Name

First Name

Middle Name

Address

City

State Zip Code

County

Phone
- -

Gender
MaleFemale

Social Security Number

Date of Birth

Race

Primary Language Spoken

PRIMARY INSURANCE If uninsured, please type "none" in the insurance Company Name.
Insurance Company Name	Insurance Phone Number - -	Insurance ID	Insurance Group Number

PRIMARY INSURANCE

If uninsured, please type "none" in the insurance Company Name.

Insurance Company Name

Insurance Phone Number
- -

Insurance ID

Insurance Group Number

SCHEDULING INFORMATION
Clinic Location School Location Requested Time: Day: Time:

SCHEDULING INFORMATION

Clinic Location

School Location

Requested Time: Day: Time:

Contact Information We will contact you within 24 hours of receiving your information.
Name Referring Clinic	Phone - - E-mail	Comments:

Contact Information

We will contact you within 24 hours of receiving your information.

Name

Referring Clinic

Phone
- -

E-mail

Comments: