Suite 100 2754 Hwy 276 Rockwall, TX 75032
Last Name: ________________________ First Name: _______________________
Last Name: ________________________ First Name: ________________________
Street: ____________________________ City: ____________ Zip code: _________
Home phone #: ____________________ Work phone #: ______________________
Employer: _________________________ Cell phone #: ______________________
Spouse Cell phone #: _________________________
Email Address: __________________________________
How would you like to be notified with reminders of services due?
mail phone email
How did you become aware of our hospital?
Internet / search engine: ________________
Past Client of Dr. Gentry's
Emergency contact name and phone# (if you are not available): _________________________
Payment is due when services are rendered. We accept cash, check, VISA and MC.
Sorry no billing or open accounts.