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
