New Patient Packet

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New patient history form

New patient history form

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)

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:

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

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