Reserve Your Spot Fill out this form to reserve your spot today! Select a Doctor* -- Select -- Callie Hollenshead, MD/Highland Park Jill Waggoner, MD/Charlton Please select a doctor. First Name* Please enter your First Name. Middle Name Last Name* Please enter your Last Name. Maiden Name Street Address* Please enter your Address. Street Address 2 City* Please enter your City. State* -- Select -- AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaInternationalIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington, DCWest VirginiaWisconsinWyomingGuam Please select a state. Zip Code* Please enter your zip code. Preferred Phone Number* Please enter the preferred phone number. Patient’s Social Security Number* Please enter the patient's social security number. Please enter a valid social security number. Patient’s Gender* Please enter the patient's gender. Marital Status -- Select -- Single Married Divorced Widowed Other Race Patient's Date of Birth* Please select date of birth. Would you like to extend your membership to additional family members? If so, how many? -- Select -- Add 1 Family Member Add 2 Family Members Add 3 Family Members Email Address* This isn't a valid email address. Please enter your email address. Family Member #1 Full Name Family Member #1 Date of Birth Family Member #2 Full Name Family Member #2 Date of Birth Family Member #3 Full Name Family Member #3 Date of Birth How did you hear about Premier Wellness? -- Select -- Patient at Methodist Uptown Medical Group Word of mouth referral Google Search D Magazine ad Other Please specify how you heard about Premier Wellness What Would You Like To Sign Up For? Travel Medicine Personalized Services Meet Your Doctor Submit Texas law prohibits hospitals from practicing medicine. The physicians on the Methodist Health System medical staff are independent practitioners who are not employees or agents of , Methodist Health System, or any of its affiliated hospitals.
