Raj Dalal, M.D. Professional Association Board Certified in Internal Medicine, 192, Abner Jackson Parkway, Lake Jacskon, TX-77566 Your primary doctor for complete care: Diagnostic, therapeutic and preventive health.
Raj Dalal, M.D. Professional AssociationBoard Certified in Internal Medicine,192, Abner Jackson Parkway,Lake Jacskon, TX-77566 Your primary doctor for complete care:Diagnostic, therapeutic and preventive health.

Patient Forms

Want to save time during your visit with us? Please print and fill out the first two forms for your first appointment.  Third form is for your following appointments.

New Patient Information-Medical
This is the medical information form for the first visit to the office. Please print and fill the form with all details you can.
history form 2016.doc
Microsoft Word document [124.0 KB]
Patient Demographics
Please print and fill the form with all details you can.
patient INFO-2016.docx
Microsoft Word document [19.3 KB]
Follow up visit form
Please print and fill the form with all details you can. This form is to be used after you already have established with Dr .Dalal as primary doctor
Follow-up questions 2017.docx
Microsoft Word document [17.1 KB]
Discount Lab Order-for self pay or high deductible plans
Please print and fill the form with all details you can.
Discount lab order.doc
Microsoft Word document [47.0 KB]
Notice of Privacy Practices
Please take time to read this. This is a requirement.
Notice of Privacy Practices-English deta[...]
Microsoft Word document [54.5 KB]

Don't forget to bring your insurance information with you

In order to register and treat you promptly, we request that our patients bring their current insurance information with them for each visit.

We accept most types of health insurance. Please contact us for further details.

Schedule an Appointment

Phone:

(979)-285-0007

New patients accepted (age 15 and older)

 

Monday to Thursday: 8:00 A.M. to 5:00 P.M.

(Closed for lunch: 12:00 Noon to 1:00 P.M.)

Friday: 8:00 A.M. to 12:00 Noon (At times closed on Friday)

Raj Dalal, M.D.

Primary care physician,

Board Certified in Internal Medicine,

 

192, Abner Jackson Parkway

Lake Jackson, TX- 77566

Connect With Us on Facebook:

Recommend this page on:

Print Print | Sitemap
© RajdalalMD