Schedule Appointment

Patient Information

Patient Forms

HSC PT Registration Info

Texas HIPAA Medical Release Form

Patient Referral form for House Call

(Provider Home Visit Services)

Date

Referring Agency / Individual

Referring Ag / Ind. Ph. #

Fax

Patient's Name

Insurance

Date of Birth

Age

SS #

Gender

Male Female

Language

Race

Interpreter Needed

Home / Residential Address

City

Zip Code

Phone Number

Alt. Phone Contact

Family Emerygency Contact

Name

Phone

Relation

Any Known Medical Conditions / Hx

About Us

Social Links

Office Hours

Mon 08:30 am – 06:00 pm
Tue 08:30 am – 06:00 pm
Wed 08:30 am – 06:00 pm
Thu 08:30 am – 06:00 pm
Fri 08:30 am – 04:00 pm
Sat 10:00 am – 02:00 pm (2nd and 3rd Saturdays)
Sun Closed

Business Hours: (U.S. central time)
Monday -Thursday, 08:30 am-6:00 pm
Friday: 08:30 am – 4:00 pm
Saturday: 10:00 am – 2:00 pm (2nd and 3rd Saturdays of the month)
Sunday: Closed

Monday 08:30 am – 06:00 pm

Tues Day 08:30 am – 06:00 pm

Wednesday 08:30 am – 06:00 pm

Thursday 08:30 am – 06:00 pm

Friday 08:30 am – 04:00 pm

Saturday 10:00 am – 02:00 pm -

(2nd and 3rd Saturdays)

Sunday Closed

Contact Info

9304 Forest Lane, Suite S125, Dallas, Texas 75243, United States
469-577-4009
214-553-7778
Family Clinic email
Info@healthsuccessclinic.com
Healthy House Call Providers
admin@healthyhousecallproviders.com

Find Us