Patient Forms

Patient Forms

We are happy to provide our office forms for convenient download on your home computer. Please print and complete the forms below, and bring them with you to your child's appointment. Questions about which forms you need? Please call our office and our courteous staff will assist you in preparing for your child's visit.

The five forms below are required to be completed annually.  Once completed, please send to our office via email at [email protected] or by fax 281-485-9469.

• Family Registration Form
• General Consent to Treat Form
• Portal Enrollment Form
• Credit Card On File Authorization Form
• Assignment of Benefits

Family Medical History Form

• Medical History Form

Medical Release Form

• Medical Release Form

18 + Demographic Form:

• Adult Registration Form

Office Policies:

• Notice of Privacy Practices
• Financial Policy
• Office Policy
• Code of Conduct
• Divorce/Separation Policy

Assessment Forms:

• Vanderbilt Assessment - Parent (Initial)
• Vanderbilt Assessment - Parent (Follow up)
• Vanderbilt Assessment - Teacher (Initial)
• Vanderbilt Assessment - Teacher (Follow up)

Other Forms:

• Easy Pay FAQ's (Credit Card on File)
• Parent Flu Waiver Form
• COVID-19 Pfizer EUA
• COVID-19 5-11 yr Pifzer EUA
• BCBS Continued Access to Providers Form

In order to view or print these forms you will need Adobe Acrobat Reader installed.
Click here to download it.