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Fayette
Alternative Medicine Clinic
Dr. Cody B. Doyle
1495 Hwy 71 West,
Suite D, La Grange,
Texas. 78945
Office: (979) 968-6400
Fax: (979) 968-6407

New Patient Scheduling

Fill out the following form to schedule an appointment with our office. We will confirm the appointment via email.

Please note: Your privacy is 100% assured.

* Name:
* Street Address:
* City:
* Email:
* Daytime Phone:
Evening Phone:
Referred By:
 
Preferred appointment time:
(We will try to accommodate your requested time.)
Time Day Month
am
pm
Optional: Print and complete required forms to expedite your office visit.
 
Optional Comments: Complete the area below if you would like us to check your insurance coverage
 
Health Insurance Company:
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Patient Date of Birth:
 
If the information on your health card does not match the above or there is additional information, please include it below: