Patient Forms
You will need a PDF reader in order to download these forms. If you do not have one installed on your computer, you may install Adobe's free Acrobat® Reader® here:
New Patient Forms
You may print out and complete the following new patient forms at home and bring the completed forms to your child's first appointment There are eight (8) new patient forms. You do not need to print out form 6, the HIPAA Notice of Privacy Practices. You only need to complete form 8 if you would like to request that medical records be sent to us from previous physicians.
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1) New Patient Form
You only need to fill out one of these forms for all of the children in your family. |
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2) Pediatric Health History Form
Please fill out one health history form for each child in your family. |
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3) Medical Photography Release/Approval
You only need to fill out one of these forms for all of the children in your family. |
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4) ImmTrac Texas Immunization Registry Consent Form
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services. The immunization registry is a secure and confidental service that consolidates and stores your child's (under 18 years of age) immunization records. With your consent, your child's immunization information will be included in ImmTrac. Doctors, pubic health departments, schools and other authorized professionals can access your child's immunization history to ensure that important vaccines are not missed.
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5) Texas Vaccines for Children Program (TVFC) Patient Eligibility Screening Record
This form is used to determine whether your child is eligible for the vaccines paid for by the Texas Vaccines for Children Program. Please complete one form for each child.
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HIPAA
New Federal laws require us to provide assurance of privacy and to attest that we will keep your personal and medical information confidential.
Download our HIPAA Forms here:
Form to Release Medical Records
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8) Patient Authorization for Use and Disclosure of Protected Health Information (optional)
If you would like your child's complete medical record to be transferred to Adams Pediatrics, you may fill out this form online, print it, sign it, and bring it to your appointment.(You will need to complete one form for each child.) We will then send your request to your former doctor.
You may also use this form to request records from Adams Pediatrics. Again, fill out this form online, print it, sign it, and bring or send it to Adams Pediatrics. (One form for each child, please.)
Please note that we will release medical records at no charge if they are to be sent directly to another provider. Medical records released to any other person or entity will be charged according to the rulings set forth by the Texas State Board of Medical Examiners.
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ADHD Forms
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