banner with photo of Beaumont Family Practice building

JAY C. PROCTOR III, M.D.
   SHELBY ODELL "Bud" CHURCH PA-C
 LAURA MOORE, FNP-C
MICCA RIEDEL ANP-C,GNP-BC
BRUCE L. MITCHELL PA-C
HARRY JAE DOYLE FNP-C

 

 

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Most Insurances Accepted
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Forms

We have provided two different New Patient Applications. The image you see to the right can be viewed at a legible size and printed out if you click on it once, and then choose the print option from the "File" drop down menu. After you've filled it out, please bring it in to your appointment. If you would like your information e-mailed to us, we have provided an interactive form below that we would appreciate you taking a few moments to fill out. If you have any questions please give us a call at: 409.835.0524. Thank you.

Driving directions
First Name
M.I.
Last Name
Address
Date of Birth
City
State
Zip Code
Phone
Age
Current Doctor and reason for changing doctors.
Provider Requested
Who do we contact in the case of an emergency?
Emergency Phone No.
Insurance Company
Insurer Address
Insurer Phone
Insurance ID No.
Do you have additional insurance?
If yes, what is your Secondary Insurance Company?
Insurance #2 ID No.
Insurer #2 Phone
Insurer Address #2
Please list any allergies or medical conditions:
Please list any medications you are taking or have taken recently.  Do you take Xanax-Alprazolam, Soma -Carisoprodol, Vicodin-Hydrocodone or Ativan-Lorazepam?
Cell #
Reason You Need To See A Doctor
Name & Type Of Specialist Seen
Are you currently having chest pains or shortness of breath?
Group No.
Email Address
Place Of Employment
Work#
Would you see our Physician's Assistant/Nurse Practitioner?
Label
Insurance Information
Personal Information
Medical History

BEAUMONT FAMILY PRACTICE
JAY C. PROCTOR III, M.D.
   SHELBY ODELL "Bud" CHURCH PA-C
LAURA MOORE, FNP-C
MICCA RIEDEL ANP-C,GNP-BC
BRUCE L. MITCHELL PA-C
HARRY JAE DOYLE FNP-C

6450 Folsom Drive
Beaumont, Texas 77706
Phone: 409.835.0524
Fax: 409.835.0632

 

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Please click on map for driving directions

BEAUMONT FAMILY PRACTICE
JAY C. PROCTOR III, M.D.
  SHELBY ODELL "Bud" CHURCH PA-C
LAURA MOORE, FNP-C
MICCA RIEDEL ANP-C,GNP-BC
BRUCE L. MITCHELL PA-C
HARRY JAE DOYLE FNP-C
6450 Folsom Drive
Beaumont, Texas 77706
Phone: 409.835.0524
Fax: 409.835.0632

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