You may request an appointment by calling 512-304-0313 inBastrop or 512-360-3698 in Smithville, or you can fill out our Request Appointment Form and fax it to us. Completing and faxing a form can give you the opportunity to take the time to provide us with all the information regarding the reason for your visit.

This form is provided for you to print and complete before your first appointment. Having this form completed will save time on your first visit.

Please print the form, complete and bring it to your appointment. All information supplied to us is considered confidential in compliance with HIPAA policies and will be added to your file. Please print/indicate your answers clearly. If you have questions, we will be happy to help you at your appointment.

Please remember that you must still bring your identification and insurance card(s) with you to each appointment.

New Patient Information Form

©2008 Riverbend Medical Group
	Bastrop, Texas 441 Highway 71 W Ste C Phone: 512-304-0313	Smithville, Texas 1501 Dorothy Nichols Lane Phone: 512-360-3698