Forms

 

 

 

 

 

 

If you are unable to create or access your Patient Portal Account or you do not have internet access, we have provided the Patient Forms below that need to be completed. You need to arrive at least one hour prior to your scheduled appointment time to complete these forms or drop them off at our office prior to the date of your appointement or you may be rescheduled. Our staff needs time to update your information into your electronic chart so your doctor has time to review before seeing you. If you have any questions regarding your portal account or the required forms, please contact our office at (512) 341-8001.
Thank you.

1. Registration Form

2. Health History Form
3. Financial Policy Acknowledgement
4. HIPAA Notice of Privacy Practices
5. Review of Systems

6. Annual Well Woman Exam Information

Medical Record's Release Form   Use this form "only" if you need to "Request" or "Release" your Medical Records.  This form "Must" be completed in its entirety and signed prior to records being released/transferred.)  A fee of $25.00 is required prior to your records request being processed)

 

Spanish

  1. Patient Registration Form - Spanish
  2. Health History Form- Spanish
  3. Financial Policy Acknowledgment- Spanish
  4. HIPAA Notice of Privacy Practices - Spanish
  5. Review of Systems - Spanish

Medical Records Request (spanish) Use esta solicitud "solamente" si necesita "Solicitar" o "Liberar" sus registros médicos. Esta solicitud debe ser completada en su totalidad y firmada antes de que los registros sean liberados/transferidos). Se requiere un cobro de $ 25.00 antes de procesar su solicitud de  registros)

 

 

 

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