Patient Forms

 Download and print out the form.





  Complete every form space leaving nothing blank.





 Fax or email the forms, then call us after 1 week and leave a message.

We will call you back and schedule your evaluation.




IMPORTANT:Please fill out ALL form spaces and include a copy of your valid Texas I.D. and Insurance card.

We will not process the forms with out them.


  


Adult Registration Form
   Please Note: We do not accept new adult Medicaid or Medicare patients.

Adult Change of Insurance Form


 
Child Registration Form
 
Child Change of Insurance Form



 Agency/Foster Registration Form






Change of Address Form

Records Request/Authorization to Release Information
Note: All authorization to release information forms must come with a copy of the authorizing party's drivers license or it will not be processed.

Authorization to have someone else bring the patient to appointments.
If you would like a family member or friend to help bring the minor child patient to appointments from time to time, please use this form to give
your permission. No other form of permission can be accepted.

Adult New Year Update Form

Child New Year Update Form

Agency/Foster Child New Year Update Form

Policy Notice and Privacy Practices

Medical History Form