​Fillable (type and print) Patient Forms

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For our patients' convenience, we offer all the forms you need right here.  Many of our patients prefer to type in their information rather than writing out everything by hand which is why we have made almost all of our forms fillable.  However, if you prefer to fill out your forms in a more traditional manner, we have printed copies available for you in our office:

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Forms to Bring With You:

• Patient Registration / Updated Information Form

• Financial Responsibility Agreement Form

• Receipt of Privacy Practices Acknowledgement and Patient Record of Disclosures Form

• Patient Portal Registration Form

• Request of Information (Incoming)

 

Other Forms:

• Notice of Privacy Practices for Protected Health Information (retain for your reference)

• Request of Information (Outgoing)

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Vaccination Forms (Print Only):

• Texas Immunization Registry (ImmTrac) Consent Form (for other ImmTrac forms click here)

• COVID-19 Vaccine:

  • Emergency Use Authorization Fact Sheets for:​

    • Moderna​

    • Johnson & Johnson

• Hepatitis B Vaccine (COMING SOON):

  • FDA Fact Sheet

• Human Papillomavirus (HPV) Vaccine (COMING SOON):

  • FDA Fact Sheets for ​Gardisal 9​

• Influenza Vaccine - Flucelvax​ (Preservative Free) (COMING SOON):

  • FDA Fact Sheet​

• Pneumonia Vaccine (COMING SOON):

  • FDA Fact Sheets for:

    • Pneumovax 23

    • Prevnar 13

• Tetanus and Diphtheria Vaccine (COMING SOON):

  • FDA Fact Sheet​