New Patient Appointment for Adolescent Contraception

Already a Patient? Please use your MyChart app or call your Clinic directly for appointments or questions.

Is this a Medical Emergency? Please call 911 or go to your local Emergency Room immediately.

For New Patients

Please complete the form below and we will contact you within one business day. If you’d like to make your initial appointment by phone, please call us at 214-645-8300 or 817-882-2400.

All fields required unless indicated.

First Name* Last Name* Date of Birth* Gender*

Email* Phone* Mailing Address* City* State* ZIP* Preferred Appointment Type*

Preferred Location (Optional)

Insurance Provider (Optional)
If not listed, your insurance provider is not currently accepted.

Reason for Visit*