Anyone interested in becoming a patient at TFWC is required to complete an application for consideration. Our Medical Director, Dr. Ron Guevara will review each application. Please give us up to two weeks to get back to you on our decision.

Please enable JavaScript in your browser to complete this form.

Today's Date *

Name *

First

Last

Applicant's Date of Birth (MM/DD/YYYY) *

Email *

Phone Number *

What current Chronic Issues do you have? (Diabetes, High Blood Pressure, High Cholesterol, Anxiety/Depression, etc) *

What are your current prescription medications and vitamins? Please include the dosage and how many times per day you take them *

What past surgeries have you had in your lifetime? *

What are your short-term & long-term health & wellness goals? *

Who was your previous Primary Care Doctor? *

What concerns or issues do you need to discuss with the Doctor on your first visit with us? (MUST HAVE A COMPLAINT/ISSUE TO BILL YOUR INSURANCE) *

Do you have medical insurance? If yes, please upload a photo of the FRONT & BACK of the Insurance Card. *

• No, I am a selfpay patient.
• Yes, I have medical insurance

Please upload the FRONT of your Insurance Card(s). If we do not receive this information, your application will NOT be accepted.

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please upload the BACK of your Insurance Card(s). If we do not receive this information, your application will NOT be accepted.

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please upload the FRONT of your Driver's License. If this application is for a minor, upload one legal parent/guardian's Photo ID. If we do not receive this information, your application will NOT be accepted. (Self pay patients MUST provide their Photo ID/Driver's License only, this is for your safety to have a photo of YOU in your chart due to identity theft risks.) *

Drag & Drop Files, Choose Files to Upload

What services are you most interested in receiving from us? Check all that apply. *

• Primary Care
• Annual Wellness Preventative Elite Physical
• Functional Medicine Nutritional Counseling
• Hormone Replacement Therapy
• Allergy Testing & Immunotherapy
• EEG Test / Brain Health Scan
• Laser Therapy
• IV Therapy
• Wellness Injections

Which Health Care Professional do you want to see at our clinic(s)? Check all that apply. *

• Ron J Guevara, DO
• Kristie Anguiano, DNP, APRN, FNP-BC
• Daniela Young, MSN, FNP-C
• Gabriela Saenz, MSN, APRN, FNP-C
• Eileen Widrick, PA-C
• Marka Dredla, FNP-C
• Amie Guevara, BS, FMNC
• All, I don’t have a preference

Which clinic location(s) do you prefer? Check all that apply. *

• Calallen Clinic ~ 15406 Northwest Blvd, Ste B; Robstown, TX 78380
• Southside Clinic ~ 6326 Yorktown Blvd, Ste 8; Corpus Christi, TX 78414

By submitting this application, I acknowledge that I've provided in connection with this form true & correct information to the best of my knowledge. *

• Yes, I agree

By submitting this application, I understand that any false statements or deliberate omissions on this form may subject me to be terminated as a patient of TFWC. *

• Yes, I understand

By submitting this application, I understand that if I am late to my appointment, do not show up, and/or cancel within 24 hours of my appointment time, I may not be seen as a new patient at this clinic and may not be rescheduled. *

• Yes, I understand

By submitting this application, I understand that this application submission is not a guarantee that I will be accepted as a patient. *

• Yes, I understand

By submitting this application, I understand that Texas Family Wellness Clinic DOES NOT prescribe Narcotic Medications such as, but not limited to – Hydrocodone, Codeine, Oxycodone, Opium, Xanax, Alprazolam, Clonazepam, & Valium. *

• Yes, I understand

By submitting this application, I understand that Texas Family Wellness Clinic does not prescribe weight loss medications that are not regulated by the FDA. *

• Yes, I understand

By submitting this application, I understand that I must establish care with a provider at Texas Family Wellness Clinic before receiving IV Therapy Services, due to Texas Medical Board Regulations. *

• Yes, I understand

our application, hours

I understand that I must submit my photo ID and the front and back of my insurance card to verify my insurance benefits, along with this application. (Self pay patients MUST provide their Photo ID/Driver's License only). If we do not receive this information, the application is not complete & will not be accepted to review. *

• Yes, I understand

Submit