Patient Forms

Complete Your Paperwork Before You Arrive

Filling out your forms ahead of time expedites the administrative process and eases your wait at check-in.

downloads

Forms & Documents

Please click the links below to view and print the patient forms.

Registration and Health Assessment

print, complete and sign

Assignment of Benefits Form

print, complete and sign

Preventive & Diagnostic Labs

print, complete and sign

Medical Records Release Form

print, complete and sign

Notice of Privacy Practices

read only

Acknowledgment for HIPAA Form

print, complete and sign

PHQ-9 Patient Health Questionnaire

print, complete and sign

Audit C Alcohol Screening

print, complete and sign

PA & NP Consent Form

print, complete and sign

Patient Centered Medical Home Patient Compact

print, complete and sign

How to Submit

Please complete all forms and provide all required signatures. For Conroe, fax to 936-788-2844. For Spring, fax to 281-651-5451 or email patientpaperwork@affmedicine.com.

Please Also Read

You must read the Notice of Privacy Practices, then print and sign the Acknowledgment of Review of Notice of Privacy Practices.

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Spanish Forms & Documents

Please click the links below to view and print the patient forms.

Spanish-PCMH

print, complete and sign

Spanish-Medical Records Release

print, complete and sign

Spanish-Assignment of Benefits

print, complete and sign

Spanish- HIPAA Form

print, complete and sign

Spanish- APN-PA Consent

print, complete and sign

Spanish Registration and Health Assesment

print, complete and sign

Spanish Flu Consent Form

print, complete and sign

Spanish Depression

print, complete and sign

Spanish Alcohol

print, complete and sign

Spanish - Preventative & Diagnostic Labs

print, complete and sign