Austex Pediatrics

Clinical Forms

Release of records to Austex Pediatrics

This form is used to get records from your previous pediatrician to us. You will need your previous pediatrician's contact information.

Release of Records to New Physician

This form is used if you are transferring from our clinic to a new physician.

Patient Information/Registration

This form is filled out at least once a year to get current contact and insurance information for your child.

Financial Policy

This form is filled out once a year to inform you of our financial policies.

Health History

This form is used by our doctors to get information about your past medical history.

Minor Consent to Treat/Parental Pre-Authorization

This form is used to allow people other than the parents to seek medical care for your child.

Unaccompanied Minor Consent

This form allows a parent or guardian of a patient that is 16 or 17 to consent to the patient's treatment without a parent or guardian present.

18 Years of Age Adult Medical Information Form

In Texas, the age of majority is 18 and the patient is legally recognized as an adult. Once an individual becomes of age their medical information becomes confidential and the adult takes control of their healthcare. This form, filled out by the now adult patient, authorizes certain people (if any) access to their medical information.

Notice of Privacy Practices - HIPPA

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.