Scurlock Tower 6560 Fannin, Suite 724, Houston, TX 77030
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Patient Forms

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PLEASE FOLLOW THESE SIMPLE STEPS BEFORE YOUR FIRST VISIT TO OUR OFFICE:

STEP 1

Please print the following new patient forms then complete and bring them with you to your first visit:

*Be sure to bring your ID and insurance cards.

New Patient Information

New Patient Health History Form

Review of Office and Financial Policies

HIPAA Privacy Form

STEP 2

Please review this Privacy Statement, then sign the following forms and bring them to your first appointment:

Acknowledgment and Requested Restrictions

OUT OF NETWORK?

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STEP 3

If the patient is a minor, please print and sign the following form:

Consent to Treat a Minor

MEDICARE?

Form 1

Form 2

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