© 2015 by W Brad Gates, MD, PA

3108 Midway Rd, Suite 105, Plano, TX 75093   Phone: (972) 801-9100

Patient Forms

Please print and complete the Patient Forms and bring them with you to your appointment along with your insurance card and drivers license.  Please arrive 15 minutes early for your scheduled appointment.  New patients must confirm their scheduled appointment 48 hours prior to their appointment, or appointment will be cancelled by our office.

  • Medical History (Pediatric for patients under 18 years old),

  • Patient Demographics, and

  • Consent and Acknowledgement

 

Please review the Financial Policies and Privacy Practices for our office prior to signing the Consent and Acknowledgement form.

 

The Release of Records form may be used to request records from previous providers, share records with other providers or forward your records to a new provider.  Patients over 18 years of age and wish to share medical  information with family members must complete the Release to Share Medical Information form.

Annual Physical:

  • Multiple issues during a physical may require a separate appointment.

  • At least six hours fasting is required so do not eat or drink; however, be sure to drink plenty of water while fasting, you may also have one cup of plain black coffee.

  • Please know your specific benefits regarding preventive services.

  • If medical problems are addressed during the physical, copay, deductible, coinsurance will be collected.

  • Any services not covered by your insurance will be your responsibility.

  • There is a $75 fee if you miss your scheduled physical appointment.  Please call at least 24 hours in advance to cancel an appointment.