Mon-Thurs 8am to 5pm, Fri 8am to 4:30pm

+1-903-533-0644

Become a patient

We are accepting new patients

Please fill out the form below or use Adobe Reader to open and print.
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You may fax or mail to our office.
Tyler Internal Medicine 1910 Roseland Blvd. Tyler, TX 75701 FAX (903)533-0441

Please send a copy of your current insurance card(s). Do not return via e-mail due to privacy policies.


New Patient Questionnaire All fields are required.
If you have nothing to note, leave the box blank.
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Electronic signature

Tyler Internal Medicine requires that you certify your application by submitting an electronic signature. To certify your application, read the text below and provide an electronic signature (type your name) and click Submit. I certify that all the information within this form is accurate and true.