Become A Patient

 We are accepting new patients.

Please fill out the form below or use Adobe Reader to open and print.

If you do not have Adobe Reader installed on your computer, you can download it free here.
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.





Policy Holder DOB

Primary Insurance Group Number

Insurance Provider Number

Policy Holder DOB

Insurance Provider Number

Current Medical Problems

If you have nothing to note, leave the box blank.

If you have nothing to note, leave the box blank.

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.