Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Patient Forms

Authorization for Release of Medical Information (PDF)
Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF)
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF)
Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.
Contactos Preferidos

Virtual Visit Policy (PDF)
This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Patient Forms

Forms can be completed online through the patient portal or you can print them from our website and bring them with you to your appointment.

Patient Forms

Authorization for Release of Medical Information (PDF) Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Forms

Financial Policy (PDF) This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices (PDF) Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully. Aviso de prácticas de privacidad (PDF)

REQUEST AN

Are you searching for pain management in Houston, Texas? We are currently accepting new patients into our practice. To become a new patient, please fill out this contact form and request an appointment. If you’re an existing patient, please request an appointment using the form below. We will get back to you as soon as we can and look forward to helping you find relief.