Thank you for understanding that our transition to fee-for service is a decision taken after serious and thoughtful consideration for how we can best meet the needs of our patients and their families for years to come. Our commitment to providing the highest quality care remains unchanged. We are humbled by and are grateful for the trust you have placed in us; we look forward to being able to continue serving you in the future!

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* 1. What is the patient's first and last name?

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* 2. What is the patient's date of birth?

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* 3. If you have additional children, what are their first and last names?

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* 4. What are their dates of birth?

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* 5. Do you plan on continuing care with the Dallas location of Girls to  Women/Young Men's Health and Wellness?

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