Physical Exam Intake Form

Get your child’s sports physical + yearly check-up at no cost when using insurance or Medicaid!* If you only need a sports physical, the cost is only $35.

Physical Exams Appointment Request Form

Patient & Contact Information

Student First Name

Student Last Name

Student Date of Birth

Parent/Guardian First Name

Parent/Guardian Last Name

Best Contact Phone Number

Preferred Email Address

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Does your child have health insurance?

Yes

Insurance Name

Appointment Details

Type of Physical Exam

Sports Physical ONLY

Sports Physical with Annual Wellness Exam

Comments or Special Needs

Preferred Clinic Location

Location Details

Primary Care Providers: Edna Muñoz, APRN, PNP & Stephanie Pham, PA-C

Care for Kids | Alliance

3400 Texas Sage Trail, Suite 148, Fort Worth, TX 76177

Primary Care Provider: Mary Rather, APRN, FNP-C

Care for Kids | Fort Worth - Hulen

3000 S Hulen St, Suite 180, Fort Worth, TX 76109

Primary Care Provider: Jannel Davila, PA-C

Care for Kids | Frisco

11550 Legacy Drive, Suite 420, Frisco, TX 75034

Care for Kids | Mansfield

2251 Matlock Rd, Suite 103, Mansfield, TX 76063

Primary Care Provider: Beth McClean, APRN, FNP-BC

Care for Kids | McKinney

6091 W University Dr Suite 108-B, McKinney, TX 75071

Care for Kids | Plano

7212 Independence Pkwy, Suite A, Plano, TX 75025

Care for Kids | Brookhollow

4528 Dacoma Street, Suite 100, Houston, TX 77092

Primary Care Provider: Dr. Jaime Herrera, MD

Care for Kids | Channelview

15727 Wallisville Road, Suite 150, Houston, TX 77049

Primary Care Provider: Jordan Wiggins, APRN, CPNP

Care for Kids | Conroe

215 S Loop-336 W, Suite 600, Conroe, TX 77304

Primary Care Provider: Tiffiny Williamson, DNP, FNP-C

Care for Kids | Cy-Fair

6807 Hwy 6 N, Unit 0054, Houston, TX 77084

Primary Care Provider: Dr. Aziza Kedir, MD, FAAP

Care for Kids | Humble

20418 US-59, Suite A, Humble, TX 77338

Practice Partner: Charla Reid, APRN, CPNP-PC

Care for Kids | Katy - Cinco Ranch

23730 Westheimer Pkwy, Suite N, Katy, TX 77494

Care for Kids | Katy - Morton Ranch

22720 Morton Ranch Road, Suite 150, Katy, TX 77449

Primary Care Provider: Linda Chhay, MSN, APRN, CPNP-PC

Care for Kids | Pearland

2803 Business Center Drive, Suite 118, Pearland, TX 77584

Practice Partner: Bridget Heard, FNP-BC

Care for Kids | Sugar Land

15551 Southwest Freeway, Sugar Land, TX 77478

Practice Partner: Marili Jackson, MSN, APRN, CPNP- AC/PC

Care for Kids | Tanglewood

1814 Fountain View Drive, Houston, TX 77057

Care for Kids | Webster

19325 Gulf Freeway, Suite 180, Webster, TX 77598

Practice Partner: Dr. Jessica Moore, MD, FAAP

Care for Kids | Willowbrook

17395 Tomball Parkway, Suite 3A, Houston, TX 77064

Primary Care Provider: Monica Wright, MSN, APRN, CPNP-AC

Care for Kids | The Woodlands

1640 Lake Woodlands Drive, Suite E, The Woodlands, TX 77380

Primary Care Provider: Deneesha Jones, APRN, CPNP-PC

*Some health plans, including Medicaid/CHIP plans, may cover the full cost for one well-child visit per year for eligible patients. Every health plan is different, so check with your health plan carrier for coverage details. Families without insurance are offered a self-pay rate. For more information about costs, call us at (682) 267-0452.*