New Patient Forms

Please complete this New Patient Questionnaire to enable our clinical and administrative staff to prepare for your first visit and to make your check-in for your appointment quicker and easier.

INSTRUCTIONS: Our questionnaire consists of four (4) documents. To complete a document, simply fill out the fields with the requested information. While most of the fields are optional, certain fields, marked by asterisks, must be completed. When you have completed a document please review your entry, click the Submit button to move to the next document. Please don't use your browser's Back or Forward buttons. Use of these buttons may 'undo'/'redo' your recent actions and may result in errors.

Please note that the information you will submit will be encrypted for your protection and goes directly to our office. We appreciate the time that you will spend providing the information helping us prepare for your visit.

Thank you and please call our office (713) 622-1707 or email to info@maryrileydds.com if you have any questions.

To complete the questionnaire, please click here: