Forms

The following are forms that need to be filled prior to our first clinic visit:

Now that I am online, there are a few options for filling out forms. You do it the old fashioned way print it, fill it out, take a picture or scan the signed document and email (pratistha.strong@gmail.com) it to me or fax it to 432-614-2599:

You can use Google Forms and do the same submission online. At this point I do not have a Medical Release of Information form or the CMS Opt-Out form that is equal to the Google Forms.

  • Medical Release of Information (You have to print this and sign it. Otherwise hospitals and doctor’s offices will not accept this form. This is the same as above.)
  • CMS Opt-Out This is only for patients with Medicare. (You have to print this and sign it. This is the same as above.)

For return phone visits, it is helpful if I know what symptoms you are having for your visit. Please fill the following form out:

The following are for reference only. You do not need to print this or sign it.