These forms
are for
Physicians’
Center only
– not for the
Central Texas
Weight Loss
Center
Patient Forms
Click on any icon below to download a printable PDF file of that form. Please fill out and bring the top seven forms to your first appointment. Thanks!
Registration Form - basic patient information, responsible party and emergency contact.
Medical History Form - patient medical history, family and medication history.
Patient Consent Form - authorization to release info and leave messages with family members.
Information Release Form - detailed authorization to release information to 3rd parties.
Financial Policies - financial responsibility, treatment and privacy notice consent.
Chart/Contact Authorization Form - authorizes who can attend your exams or receive information.
Privacy Practices Acknowledgement Form - acknowledges receipt of our privacy notice.
Notice of Privacy Practices - describes how medical information may be used and disclosed.
For a free download of Acrobat Reader, please click here
3721 Williams Drive • Georgetown, Texas 78628
(512) 869-7310 • Metro (512) 930-9130
