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Dr. Jerome Lisk
Patient Forms & Information

New Patient FormsFollow Up Appointment Forms

New Patients

New Patient Packet
Complete the form and email it to us, fax it or print the form and bring it with you to your scheduled appointment along with a photo ID and insurance cards. 

Please see instructions on emailing & faxing forms at the bottom of this page.

If you have any questions, feel free to contact our office at: 940-383-1770

All forms are in Adobe PDF format. To view and complete the PDF forms on your computer or device you will need free: Adobe Reader (click link to install)

Use this form if emailing back to us.
It uses a password and encryption.
Password: 940-383-1770 (with dashes, exactly as shown.)

Use this form if not emailing back to us.
Same form as the one above but does not use a password and is not encrypted to send over internet.

Emailing, Faxing & Password

To Fax the New Patient Packet to our HIPAA fax at: 833-992-0840.
The form can be completed on your computer by saving the form and opening & filling in the form with free Adobe Reader (or by hand) then print and fax.

To Email the New Patient Packet: Save the Password Protected PDF form below to your computer. Open & fill in the form with free Adobe Reader. Save the filled in form then attach it to an email and send it to:

The Password version uses our phone number as the password: 940-383-1770 (with dashes, exactly as shown). Using the password encrypts the form to be sent over the internet for added security and keeps the form secure on your computer.