PATIENT FORMS
NEW PATIENT FORM
(ADULT)
Required
Form for new adult patients.
This form asks for:
Contact and demographic info
Medical History
Surgical History
Medication list
Current Problems and Concerns
Fill out ahead of time or in the office in order to maximize face-to-face time.
NEW PATIENT FORM
(CHILD)
Required
Form for new child patients.
This form asks for:
Contact and demographic info
Medical History
Surgical History
Medication list
Current Problems and Concerns
Fill out ahead of time or in the office in order to maximize face-to-face time.
CODE 1
MEMBERSHIP AGREEMENT
Required
The nuts and bolts of being a Code 1 Concierge Care member.
NOTICE OF PRIVACY PRACTICES (HIPAA)
Informational
What we can and cannot do with your Protected Health Information (PHI).
Informational only.
ACKNOWLEDGEMENT OF PRIVACY PRACTICES
Required (please sign)
Your consent (or not) to our Privacy Practice plan.
URGENT CARE/TELEMEDICINE
(SINGLE VISIT)
AGREEMENT
Required
Form for new adult, SINGLE VISIT patients.
This form asks for:
Contact and demographic info
Medical History
Surgical History
Medication list
Current Problems and Concerns
Fill out ahead of time or in the office in order to maximize face-to-face time.
CONTROLLED SUBSTANCES AGREEMENT
Required
For patients who will be receiving regularly prescribed controlled medications. Required by the State of Texas
