Sherry Nussbaum, M.D., P.A.
1008 North Bowen Road
Arlington, TX 76012
(817) 861-2288

Patient Registration


Patient Information

Insurance Information


We apologize but we are unable to accept Cook Childrens STAR program or any program with state Medicaid including: Traditional MDCD, TMHP, or other Medicaid subprograms of AETNA, UHC and other private insurance companies. *

Parent/Guardian #1 Information

Guarantor Relationship to Patient: *

Parent/Guardian #2

If you wish to add a second parent/guardian, please fill out the following information. 
Otherwise, skip down to Emergency Contact Information.
Guarantor Relationship to Patient:

Emergency Contact

If you wish to add an Emergency Contact, please fill out the following information. 
Otherwise, proceed to the next page. 



AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to the physician of the surgical and/or medical benefits, if any, otherwise payable to me for his/her services as described, realizing I am responsible to pay non-covered services.

AUTHORIZATION TO RELEASE INFORMATION:  I hereby authorize the physician to release any information acquired in the course of my treatment necessary to process insurance claims.