New Patient Packet

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New patient history form

New patient history form

Address *
Address
City
State/Province
Zip/Postal

Current Medications

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 (please list age and health conditions)

Siblings

Family with an autoimmune condition ( lupus, rheumatoid arthritis, etc. ) *

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:

Pharmacy Address *
Pharmacy Address
City
State/Province
Zip/Postal

Patient Registration

Advanced Rheumatology of Houston

10857 Kuykendahl Rd Suit 120
The Woodlands, TX 77382

Office: (281) 766-7886

Fax: 281-719-9320

() No change in address, phone number

Last
First
Middle
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

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: Developed by the Texas Pain Society, April2008 (www.texaspain.org)

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

Cancellation and No-Show Policy