Forms

If you think you may qualify for services, call 214-821-3820 for a pre-screening. If you qualify, you will be directed as to which forms below to download and complete.

doctorside

Form Description Lang Format
Application Application Form (Checklist, Intake, Financial Assistance Policy, Consent Agreement) English PDF
Editable Application Editable Application Form (Checklist, Intake, Financial Assistance Policy, Consent Agreement) English MS Word
Aplicación Aplicación (lista de verificación, Intake, Politica de Asistencia Financiera y Descargo de Responsabilidad, Acuerdo de Consentimiento) español PDF
Aplicación editable Aplicación editable (lista de verificación, Intake, Politica de Asistencia Financiera y Descargo de Responsabilidad, Acuerdo de Consentimiento) español MS-Word
Medical Release Release for Medical Records and Imaging Studies English PDF
Supporter Statement Used for verification of support from someone other than your spouse English PDF
Employer Verification Verification of employment and insurance English PDF
Volunteer Interest Volunteer Interest Form (for Individual) English PDF
Notice of Private Practices Notice of Private Practices Form English PDF
Notice of Private Practices Notice of Private Practices Form Spanish PDF