New Patient Information

To facilitate your initial visit with us, please complete one of the first two new patient packets depending on whether or not your child is a newborn (age less than 30 days). You may fill them out online, print and bring the completed forms with you. Alternatively, you may complete, save and submit them electronically (upload completed forms here).  In addition, if your child has already received any immunizations, please bring your child’s immunization (shot) record. We look forward to seeing you!

 

New Patient PACKET for NEWBORNS

9pgs includes forms: Patient Info, Financial Policy, Privacy Policy, Pediatric History, Newborn, ImmTrac Registration, Permission to Treat

 

New Patient PACKET for Non-NEWBORNS

8pgs includes: Patient Info, Financial Policy, Privacy Policy, Pediatric History, Medical Records Request, ImmTrac Registration, Permission to Treat

 

Release Form – Medical Records TO Hometown Pediatrics

To request your child’s previous medical records from a physician, group, clinic, or hospital be sent to Hometown Pediatrics

 

Release Form – Medical Records FROM Hometown Pediatrics

To request your child’s medical records from Hometown Pediatrics be sent to an alternate physician, group, or health agency

**Effective October 10, 2013, Hometown Pediatrics will change our medical records policy in accordance with the legal guidelines provided by the Texas Medical Board and Texas Medical Association. We will provide a medical summary, which will include the immunization records, at no charge. If you are requesting complete detailed medical records there will be a charge of $25.00 for the 1st 20 pages and $0.50 per page thereafter. This will include any records sent to another facility if Hometown Pediatrics is not referring the patient. Thank you for your understanding.

 

Medical Treatment – Authorization for a Minor

For the parents or legal guardians wishing to grant permission for another adult to make health care decisions for their minor(s)

 

Notice of Privacy Practices

Learn more about how your medical information may be used and disclosed. See how you can access this information. This is not a required form. It's a notice.

 

Patient Form Upload

Click the button below to securely upload your completed pdf. Electronically submitted forms should be uploaded by 4pm the day prior to your child's scheduled visit. If later, please also bring a printed copy of your forms.