Request an Appointment

Please fill out the details in the form below to submit a new appointment request for Diagnostic Pain Center

DISCLAIMER: If you are experiencing a medical emergency, please call 9-1-1. This form is for appointment requests only.

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Patient Contact Information

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First name *

Middle name

Last name *

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Email *

Phone number *

Phone type *Select typeHomeMobileWork

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Preferred location *Select locationDPC-Bee CaveDPC-MopacTexas Herb Clinic

Provider to see *Any, first availableCharlottle Loflin NP-CDr. John Gburek MDDr. Robert Marks MDDr. Sauman Rafii MD

Date of birth *

Patient Status (optional)

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Are you a NEW or ESTABLISHED patient with DPC?NEW or ESTABLISHEDEstablished PatientI am not sureNew Patient

Appointment Details (optional)

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Reason for appointmentSelect reason for appointmentFollow UpNew PatientNew Patient - Telemed (Limited)THC Rapid Registration - New Medical Cannabis

Please give us a few details about your pain/condition to ensure we get you with the correct provider.

How did you hear about us?Select request sourceEstablished PatientFriends/FamilyGoogle/OnlineLaw FirmLeading Reach

Financial Responsibility (optional)

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Please give us a few details about your financial responsibility.Financial ResponsibilityAuto Accident/Injured (NOT Work Related)InsuranceSelf-Pay (Cash)Worker's Comp

Insurance companySelect insurance companyNo insuranceNot listedAdd laterAETNAAMERIGROUP TexasAvMedBlue Cross and Blue Shield of TexasCIGNAFirst HealthGovernment Employees Health Association (GEHA)Health First Health Plans (HFHP)HumanaMedCost Benefit ServicesMedicaid (Florida)Medicaid (Texas)MedicareMEDICARE B-TX: NOVITAS SOLUTIONSMeritain HealthNeighborhood Health PartnershipOxford Health Plans (A United Healthcare Company)Sunshine State Health PlanSuperior HealthplanTRICARE for LifeTRICARE HUMANA EAST REGIONTriCare WestUMRUNITED HEALTH CARE/ MC ADVANTAGEUnited HealthcareVA HealthcareWellCare of Florida

Are you being represented by an attorney regarding this accident/injury?Are you being represented by an attorney regarding this accident/injury? NoUnknownYes

Policy ID number

Is the patient the insurance holder?

• Yes
• No

Submit Request