Apply Online

For renewing patients only

Application for Medical / Dental Services

Important Note: To be completed ONLY by existing patients who are requalifying.

If you are a new applicant, you must visit our Admissions Department to apply.
Renewing patients, please enter all of the required and applicable fields in the application below.
Required fields are indicated by a red asterisk (*).

First Name

Middle Name

Last Name

Street Address

City

Zip

I'm applying for:

Medical Services Only

Dental Services Only

Both Medical and Dental Services

Today's Date (Use Date Picker)

Date of Birth (MM/DD/YYYY)

Sex

Male

Female

My status is:

First Time Applicant

Renewing Patient

Race

Ethnicity

Preferred Language

Daytime Phone

Do You Receive Text Messages?

Yes

If you answered Yes, you will receive a text message from us when your application has been processed.

Cell Phone

Email Address

Marital Status

Emergency Contact Person

Emergency Contact Phone

Emergency Contact Relationship to Applicant

My Place of Employment

Total income your entire household earns each month (before taxes):

How many people are currently in your household? This number must reflect the number of dependents you claim on your tax return. If not, please explain.

Do you receive any of the following? (Check all that apply)

Receive Medicaid

Receive Medicare

Receive Veterans Benefits

Have Medical and/or Health Insurance

Receive or Applied for Social Security Disability

None of the above

Bethesda Medical patients have the option to have a Patient Portal account. With the Patient Portal you can request medical appointments, upload income information, send & receive messages, view lab results, and more.

Would you like a Patient Portal account?

Yes

If you answered Yes, please enter the email address to be used by the Patient Portal.

Upon setup completion by Bethesda Health Clinic, you will receive an email with your account username and temporary password to complete your patient portal registration.

How did you learn about Bethesda Health Clinic?

Dental Applicants Only

Do you have Dental Insurance?

Yes

Have you had a dental checkup in the last 6 months?

Yes

If yes, what was the result?

Dental services NOT provided: implants, complete dentures, orthodontic treatment, periodontal surgery, sedation or nitrous oxide, and select impacted dental extractions.

I Understand:

The initial dental appointment fee is $70. A non-refundable deposit of $50 is required to schedule your first dental appointment. $20 is due on the appointment date.
Fees for all dental services are in addition to the initial dental appointment fee.
Dental appointment fees will vary based on the type of services to be provided.
A 50% deposit is required for dental services when the appointment for those dental services is made. The remaining 50% is due on the appointment date.
A $40 deposit is required for hygiene services when the appointment for those services is made.
You must provide at least 24 hours advance notice to cancel or reschedule your dental or hygiene appointment. Failure to appear for your appointment without 24 advance notice will result in a loss of up to $50 of your deposit.
If you arrive 10 or more minutes late to your appointment, you might lose your appointment and your deposit.

Dental Conditions and Guidelines

Dental Applicants Only - By checking the box I confirm that I have read and agree to the Conditions and Guidelines above.

All Applicants

I Understand:

I am required to pay my office visit co-pay, dental initial visit fee, and/or any other office visit fees each time I have an appointment at Bethesda. If I cannot pay, I may not receive care and may be referred to a patient advocate to be matched up with other resources. All co-pays and fees must be paid in cash or by credit card.
Fees for all dental services, labs, x-rays, women’s health, and specialty services are separate. They may be in addition to my medical office visit co-pay, dental initial visit fee, and will vary depending on the test or procedure.
If I miss a scheduled appointment and fail to provide at least 24 hours advance notice it could impact my eligibility as a Bethesda patient. Failure to appear at my initial visit or the cancellation of any three appointments can result in my dismissal as a patient.
If I cancel an appointment on the same day as that appointment or if I miss an appointment and do not call ahead, I will forfeit any prepaid fees for that appointment.
If I am over 10 minutes late, to any appointment, I will not be seen.
Specialty services and referrals at Bethesda are limited. They are prioritized for patients where Bethesda is their primary healthcare provider. Not all patients will have access to specialty services and/or referrals.

Conditions and Guidlines

All Applicants - By checking the box I confirm that I have read and agree to the Conditions and Guidelines above.

Required Documents Confirmation

All Applicants - By checking the box I confirm that I must bring proof of income (check stub), a valid photo ID and latest tax return (1040 pages 1 & 2) to my first appointment, unless I have made other arrangements with the Bethesda Health Clinic Admissions Department.

Waiver of Liability for Treatment

The Medical/Dental treatment provided by Bethesda Health Clinic, a charitable non-profit organization (the “Clinic”), is provided by volunteer healthcare providers who do not receive compensation.

Texas Law (Texas Charitable Immunity and Liability Act of 1987 [as amended]), as well as Federal Law (Volunteer Protection Act of 1997), provides IMMUNITY FROM CIVIL LIABILITY for any act or omission resulting in death, damage, or injury if the volunteer was acting in good faith and in the course of his/her duties or functions within the organization.

By signing below, you acknowledge: (1) that the Clinic’s volunteer healthcare providers (such as physicians, physician assistants, registered nurses, licensed vocational nurses, pharmacists, podiatrists, dentists, dental hygienists, optometrists, or any such persons who are retired or otherwise defined or included under Texas law or Federal law) are providing health care that is not administered for or in expectation of compensation; and (2) that there are limitations on you or your family’s ability to recover damages from the volunteer or the Bethesda Health Clinic in exchange for your receiving health care services.

It is intended that this WAIVER be as broad and expansive as allowed by law.

Submit Application

By clicking the Submit button below, I hereby declare that the above information is true and correct and that I have read and agree to the Waiver of Liability for Treatment. I know that any false information could jeopardize my eligibility to receive medical and/or dental attention at Bethesda Health Clinic.

Questions?

If you have any questions regarding this process or what to bring, please call our Admissions Department at
(903) 596-8353 ext. 112 or email admissions@bethesdaclinic.org.

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