Request for Portal Registration Sign Up Here Patient First Name*Patient Last Name*Responsible Party Full NameEmail* Phone*Alternate Phone NumberPatient Date of Birth* Date Format: MM slash DD slash YYYY Have you previously been seen at 1960 Family Practice?*YesNoPhysician*Dr. Alex NguyenDr. Annie HoangDr. Michele GocuaDr Cory BuiDr. Lance PickardDr. Minni MalhotraDr. Vi NguyenDr. Madeline HuntDr. Francisco OrtizDr. Minh MaiDr. Crystal BroussardDr. Srijaya BandiDr. Jose AguirreDr. Victor EscobarDr. Carlos GutierrezDr. Douglas LaCourDr. Richard CrouseDr. Terri-Ann SamuelsDr. Thinh HoOtherDo not knowHow did you hear about us?*Demand Force EmailEmail ReminderMail ReminderPhone ReminderLiving MagazineSignageFriend or FamilyPhysician ReferralLocationWebsiteCurrent PatientSubmission Agreement* By checking this box, I understand the terms of use for this submission form as stated below. PLEASE UNDERSTAND THAT YOU ARE SUBMITTING THIS REQUEST OVER THE INTERNET. DO NOT INCLUDE ANY SENSITIVE MEDICAL INFORMATION IN YOUR APPOINTMENT REQUEST. 1960 Family Practice respects the confidentiality of your personal information and promises only to use it for internal purposes as it relates to this request. If you are uncertain about transmitting this information over the Internet, please do not submit your form. Please call our scheduling department directly and they will assist you with your appointment. 281-586-3888 option 1.