banner with photo of Beaumont Family Practice building

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

Aesthetic Procedures

Occupational Medicine

Most Insurances Accepted

VelaShape™

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.

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
MICCA RIEDEL ANP-C,GNP-BC
HARRY JAE DOYLE FNP-C
6450 Folsom Drive
Beaumont, Texas 77706
Phone: 409.835.0524
Fax: 409.835.0632

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