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Patient Forms

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Patient Intake Form

Secure digital intake form for new and returning patients.

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Encrypted patient workflow

Dynamic Patient Intake Form

Complete the intake digitally and we will generate a completed PDF record after submission.

Patient Name
Personal Details
Upload one insurance card or supporting document in PDF, JPG, or PNG format (maximum 5 MB).
Current Symptoms
Diagnosed Medical Conditions
Previous Operations & Lifestyle
Family History & Additional Symptoms
HIPAA Consent
By submitting this form, the patient acknowledges the HIPAA information and consent terms, agrees that insurance and payment responsibilities remain theirs where applicable, and authorizes the practice to use and disclose health information for treatment and billing.
Patient Information
Release Records From

Enter the hospital, provider, or facility currently holding the requested records.

Send Requested Records To
Dr. Vijaya Dasari, M.D. North Texas Gastroenterology, P.A. Denton: 2701 Shoreline Dr., Suite 101, Denton, TX 76210 Lewisville: 560 W. Main St., Suite 106, Lewisville, TX 75057
(940) 898-7488 Fax records to: (940) 243-3554 vjydasari123@gmail.com
Records Requested
Authorization and Signature
Sensitive Information Consent: I specifically authorize the release of health care information relating to HIV/AIDS, sexually transmitted diseases, psychiatric or mental health treatment, and drug or alcohol use when present in the requested records.
Secure submission | Completed PDF generated after submit