Dr. Zehra Jaffer, DNP, APRN, FNP-BC, CDCES

Patient Registration

Dr. Zehra Jaffer's
Patient Registration Form

Take the first step toward better health. Complete the form below and our team will contact you within 1 business day to confirm your appointment.

👩‍⚕️ About Dr. Jaffer — Click here for Full Bio →

DNP, APRN, FNP-BC, CDCES Duke University 15+ Years Experience

New Patient Registration

All fields marked with * are required. Your information is kept strictly confidential and used solely to prepare for your appointment.

Personal Information

Full Name *

Date of Birth *

Phone Number *

Email Address *

Address

City *

State *

Zip Code *

Appointment Details

Are you a new or returning patient? *

New Patient Returning Patient

Preferred Appointment Date

Preferred Time

Primary Reason for Visit *

Insurance Provider

How Did You Hear About Us?

Please select all that apply *

🔍 Google Search 📘 Facebook 📸 Instagram 👥 Friend / Family 🩺 Doctor Referral 🏘️ Nextdoor 💬 Other

Additional Information

Current Medications (optional)

Questions or Additional Notes (optional)

By submitting this form you consent to being contacted by Texas Diabetes & Wellness Clinic regarding your appointment. We never share your information with third parties.

✅

Registration Received!

Thank you — your registration has been sent to Dr. Zehra Jaffer's office. A member of our team will reach out within 1 business day to confirm your appointment details.

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Dr. Zehra Jaffer'sPatient Registration Form

New Patient Registration

Registration Received!

Dr. Zehra Jaffer's
Patient Registration Form