PATIENT FORMS

NEW PATIENT FORM

(MEMBERSHIP)

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

(MEMBERSHIP)

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)

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Informational

What we can and cannot do with your Protected Health Information (PHI).

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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

 

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