Patient Forms
Forms for Your Visit
These are the forms our front desk uses. Nothing is submitted through this website — bring your completed forms with you, or ask us to send them securely.
Available forms
New Patient Health History
Your medical history, current medications and allergies — bring it to your first visit.
Patient Information Sheet
Contact details, insurance information and responsible party.
Authorization to Release Medical Records
Lets us request records or imaging from another provider.
Notice of Privacy Practices Acknowledgement
How your health information is protected and used.
Financial & Insurance Policy
Our billing, copay and no-show policies in plain language.
Hearing Device Purchase Agreement
For audiology patients selecting a device.
Consent for Treatment of a Minor
For patients under 18 seen without a parent present.
Medication Refill Request
Request a refill between visits without a phone call.
Need a form sent to you? Call (214) 888-8978 and we'll send it securely.