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