Call 325-703-6670
  Call  325-703-6670

Patient Forms

Want to save time during your visit with us? Please fill out the following form and submit it on-line.  You can also print and fill out the forms below and bring them with you to your visit.

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Patient Registration Form

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Don't forget to bring your insurance information with you

In order to register and treat you promptly, we request that our patients bring their current insurance information with them for each visit.

We accept most types of health insurance. Please contact us for further details.

Call: 325-703-6670

Our business hours

Monday - Thursday08:00 AM - 12:00 PM
01:00 PM - 05:00 PM
Friday08:00 AM - 02:00 PM
If you have an emergency outside of business hours, please go to the nearest Emergency room. If you have a problem that can not wait until regular business hours, please go to an urgent care clinic or ER; otherwise, leave a message and we will get back with you promptly during regular business hours.

Patient Registration Information
PatientRegistrationForm.pdf
Adobe Acrobat document [163.4 KB]
Assignment of Benefits Form
Assignment of Benefits Form.pdf
Adobe Acrobat document [158.4 KB]
Authorization for release of Medical Information
Authorization-for-release-of-Medical-Inf[...]
Adobe Acrobat document [131.9 KB]
Authorization to Release Medical Information to Family Member
Authorization to release medical info to[...]
Adobe Acrobat document [57.9 KB]
HIPAA Privacy Rules and Notice
HIPAA Privacy Rules and Notice.pdf
Adobe Acrobat document [285.9 KB]
Privacy Practices Acknowledgment
Privacy Practices Acknowledgment.pdf
Adobe Acrobat document [77.1 KB]

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