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Book Appointment

To request an appointment, please fill out the form below. Our scheduling coordinator will contact you within 24-72 hours with your appointment options. If you would like to schedule your appointment immediately, please contact Prime Care Health Solutions: 214-613-2019

Acknowledgement and Consent

Do Not Sign or Submit until You Have Read and agree with all policies and notices provided below. If you have any questions or concerns regarding our privacy policy, communication policy, or the terms of participation, please contact us at privacy@primecarehs.com
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Our privacy notice is available here, our HIPAA notice is available here, our terms of use document is available here, and our communication policy is available here
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Your full name with date serves as an electronic signature
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Patients Electronic Signature
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Todays Date
Today's date*
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If this consent is signed by a personal representative on behalf of the patient, complete the following

Personal Representative's Name
Personal Representative's Name
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Your full name with date serves as an electronic signature
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Relationship to Patient
Relationship to Patient
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Type of Appointment*
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Appointment details

Have you already completed an online enrollment form?*
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Your First Name
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Date of Birth
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Your E-mail Address
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Your Last Name
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Your Phonenumber
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Preferred Contact Method
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Ask us any questions...
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Select the enrollment that you're interested in*

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Since you have not yet completed an online enrollment form, you may select a service above, then you will be automatically redirected to the enrollment form for that service.
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Appointment details (Part II)

Appointment Location required*

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All initial appointments from a referring provider will be conducted in referring provider’s office location. For all other appointments for our clients near the DFW area, please visit us in our Dallas office. Otherwise, long-distance clients should consider the Skype option.
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Type of Service required (select all that apply)*

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Reservation details

Type of reservation*

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For group programs, please indicate a preferred day and time (Preferred day and time required (select one)

GROUP Reservations only: Please provide a preferred day to meet*
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GROUP Reservations only: Preferred time of day*
Select a time
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For private one on one appointment, please provide 3 preferred dates and time

PRIVATE APPOINTMENT only: First choice appointment date*
PRIVATE APPOINTMENT only: First choice appointment date*
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PRIVATE APPOINTMENT only: Second choice appointment date*
PRIVATE APPOINTMENT only: Second choice appointment date*
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PRIVATE APPOINTMENT only: Third choice appointment date*
PRIVATE APPOINTMENT only: Third choice appointment date*
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PRIVATE APPOINTMENT only: First choice preferred time*
Select a time
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PRIVATE APPOINTMENT only: Second choice preferred time*
Select a time
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PRIVATE APPOINTMENT only: Third choice preferred time*
Select a time
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Payment / Insurance Options

Who will be covering the cost of the service(s) you selected?
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If you are covering the cost by yourself, you will be redirected to a page where you can complete your enrollment and make a payment.
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Your medical insurance information
Your medical insurance information
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Please provide your medical insurance information for the selected service(s). Insurance name, primary carrier's name (insured), member ID number, group number, coverage date, effective date, and customer service number.
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Your pharmacy insurance information
Your pharmacy insurance information
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Please provide your pharmacy insurance information for the selected service(s). Insurance name, primary carrier's name (insured), member ID number, BIN number, group number, coverage date, effective date, and customer service number.
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Employer information
Employer information
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Please provide the following details for your employer: Company name, company address, contact email, phone number.
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