New Patient Packet

New patient history form

New patient history form

First, Middle, and Last

Current Medications

Please list all current medication and include month/day/year.

Social History

Medical History

Please check off all applicable personal medical diagnoses received by a doctor

Surgical History (please list surgeries and dates)

Family History

Rheumatology Auto Immune Diseases As of: (if a provider has treated you or your family, please mark off your diagnosis)
Have you been under the care of another Rheumaologist in the past?

TELEPHONE COMMUNICATION PREFERENCE

CAN WE CALL HERE?
CAN WE LEAVE A MESSAGE?

CAN WE CALL HERE?
CAN WE LEAVE A MESSAGE?

CAN WE CALL HERE?
CAN WE LEAVE A MESSAGE?

CAN WE CALL HERE?
CAN WE LEAVE A MESSAGE?

So that we may better serve you, please provide the following pharmacy information:

If you do not know what Specialty Pharmacy to use, we will send your medication to Kroger Specialty Pharmacy for all Biological and Oral medication.
Pharmacy Address
Pharmacy Address
City
State/Province
Zip/Postal

New Patient Office Registration

Race
Employment Status:

Responsible Party (Party Responsible for payment):
Last
First
Middle
Address
Address
City
State/Province
Zip/Postal

Insured Party: *

Please call the office for the Notice of the Privacy Practice 281-766-7886 Ext 1

Patient Release Information

Authorization for Disclosure of Confidential Information

To release the following medical information to Advanced Rheumatology of Houston.

Check All That May Be Released:
Purpose of Disclosure:
The patient agrees that a photocopy of this authorization may be considered valid.

Informed consent and pain management agreement as required by the texas medical board reference: texas administrative code, title 22, part 9, chapter 170 3rd edition:developedbythetexaspainsociety,april2008(www.Texaspain.Org)

ADVANCED RHEUMATOLOGY OF HOUSTON Patient Consent for Use of Email Communications Letter

Cancellation and No-Show Policy

Advanced Rheumatology of Houston
Artificial Intelligence (AI) Disclosure Form

At Advanced Rheumatology of Houston, we are committed to providing the highest quality of care for our patients. As part of this commitment, we may use Artificial Intelligence (AI) tools and technology to support certain aspects of clinical care, administrative processes, and patient education.

How AI May Be Used

  • Clinical Support: Al tools may assist providers by reviewing medical information, supporting decision-making, and identifying potential treatment options. Final medical decisions are always made by your healthcare provider.
  • Administrative Support: Al may be used to streamline scheduling, documentation, and communication to improve efficiency and patient experience.
  • Patient Education: AI-generated materials may be provided to help explain medical conditions, treatments, or processes in a clear and understandable way.

Important Information for Patients

  • AI is a supportive tool, not a replacement for medical judgment. All diagnoses, treatment plans, and medical decisions are determined by your healthcare provider.
  • Your privacy is protected. Any use of Al systems complies with HIPAA and all applicable privacy and security standards.
  • If you have questions about AI use in your care, please ask your provider.

Acknowledgment

I have read and understand the information above regarding the use of Artificial Intelligence (AI) tools at Advanced Rheumatology of Houston. I understand that Al may be used in supportive roles, but my medical care and treatment decisions will always be directed by my healthcare provider.
Patient Name (Print):
Patient Signature:
Date: