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%20Member_edited.jpg

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.

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CODE 1

MEMBERSHIP AGREEMENT

Required

The nuts and bolts of being a Code 1 Concierge Care member.

Contract.jpg

NOTICE OF PRIVACY PRACTICES (HIPAA)

Informational

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

Informational only.

Privacy Policies

ACKNOWLEDGEMENT OF PRIVACY PRACTICES 

Required (please sign)

Your consent (or not) to our Privacy Practice plan.

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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.

Urgent%20Care_edited.jpg

CONTROLLED SUBSTANCES AGREEMENT

Required

For patients who will be receiving regularly prescribed controlled medications. Required by the State of Texas

Medical Prescription