Step 1 — Choose your appointment type

Visit category *

New Patient First time with our practice

Follow-up Returning established patient

Telehealth Phone or video visit

Group Home Caregiver / group home visit

Type of care needed *

Preferred visit duration *

Select your appointment type above to see duration options.

Preferred date *

Preferred time *

Your information is kept private & secure

Step 2 — Patient information

First name *

Last name *

Date of birth *

Phone number *

Email address *

Your relationship to patient

Patient's home address (visit location)

Street address *

City *

State *

ZIP code *

Any additional information for our team

Step 3 — Insurance & ID verification

Why we need this: To confirm your appointment, we verify your insurance coverage before sending a provider to your location. This protects your time and ensures there are no billing surprises. All uploads are stored securely and used only for insurance verification purposes.

Payment method *

Health insurance

We bill your insurer directly

Self-pay / cash pay

Debit / credit / HSA card

Insurance provider / company name *

Member ID / Policy number *

Insurance card — Front *

Tap to upload or take a photo

Front of insurance card • JPG, PNG or PDF

Insurance card — Back *

Tap to upload or take a photo

Back of insurance card • JPG, PNG or PDF

Government-issued photo ID

Please upload both sides of your driver's license, state ID, or passport. This is required for all new patients and for identity verification.

ID — Front *

Tap to upload or take a photo

Driver's license / state ID / passport — Front • JPG, PNG or PDF

ID — Back *

Tap to upload or take a photo

Driver's license / state ID / passport — Back • JPG, PNG or PDF

Step 4 — Review & submit

Consent & acknowledgements

I consent to be contacted by Enriched Lives Health Service, PLLC to confirm this appointment. I have read and agree to the Privacy Policy and HIPAA Notice of Privacy Practices. I understand that my insurance will be verified before my appointment is confirmed, and that I am responsible for any co-pays, deductibles, or self-pay amounts.

Submitting this form is a request, not a confirmed appointment. Our team will contact you within 24 hours to confirm your visit. For immediate assistance, call 832-323-4221.

Request received!

Thank you! We've received your appointment request. Our team will review your information and contact you within 24 hours to confirm your visit.

Check your email for a confirmation. If you need to reach us sooner, call 832-323-4221.

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Book Your Appointment

Step 1 — Choose your appointment type

Step 2 — Patient information

Patient's home address (visit location)

Step 3 — Insurance & ID verification

Government-issued photo ID

Step 4 — Review & submit

Consent & acknowledgements

Request received!