813 W. White Street, Suite 100 * Anna, Texas 75409 * T: 972.924

813 W. White Street, Suite 100 * Anna, Texas 75409 * T: 972.924.8224 * F:972.924.8226
Patient Basic Information
First Name
Email
Middle Name
Home Phone
Last Name
Mobile Phone
SSN
Office Phone
Date of Birth
Marital Status
Gender
Preferred Communication:
! Home Phone
Address
! Mobile Phone
! Office Phone
! Email
! Mail
I grant permission for the following:
City
! Please Enroll me in Patient Portal so I can access my health information online
State
Zip
Emergency Contact Name
Ethnicity
Emergency Contact Phone
Race
Preferred Pharmacy
Insurance Information
Guarantor/Subscriber/Person Financially Responsible Info:
Insurance Co.
! Self Pay
Please provide copy of Insurance card at time of visit
! Address same as above
First Name
Middle Initial
Address
Last Name
City
Date of Birth
/
/
County
Sex
State
SSN
-
-
Zip
Name of Employer
Relationship to Patient:
! Self ! Spouse ! Child ! Other
*Signature below indicates financial responsibility for all charges incurred on this account for any portion of your account not paid in full. This is a legally
binding agreement for financial responsibility for collection fees, late charges, and any legal fees for nonpayment of the account. This is also a legally binding
agreement for Anna Family Healthcare to treat and care for you and/or your child, unless otherwise noted. Please note that payment is due at time of service.
Responsible Party Signature:
Responsible Party Printed Name:
Date:
813 W. White Street, Suite 100 * Anna, Texas 75409 * T; (972) 924.8224 * F: (972) 924.8226
Disclosure and Consent Form
Patient Name
Date of Birth
Authorized recipients of my health information
Name
Relationship
Name
Relationship
Name
Relationship
The following information may be released:
People listed above
Appointment Information
Yes or No
Test/Lab Results
Yes or No
Medications
Yes or No
Procedures
Yes or No
Immunization Records
Yes or No
I understand I may revoke this consent at any time by giving written notice to Anna Family Healthcare. Until written notification is given, this
request will remain valid.
Assignment of Insurance Benefits
I hereby authorize direct payment of my insurance benefits to Anna Family Healthcare or the provider individually for services rendered to my
dependents or me by the provider or under provider supervision. I understand that it is my responsibility to know my insurance benefits and
whether or not the services I am to receive are a covered benefit. I understand and agree that I will be responsible for any co-pay or balance
due that Anna Family Healthcare is unable to collect from my insurance carrier for whatever reason.
Lab/X-Ray/Diagnostic Services
I understand that I may receive a separate bill if my medical care includes lab, x-ray, or other diagnostic services. I further understand that I
am financially responsible for any co-pay or balance for these services if they are not reimbursed by my insurance for whatever reason.
Financial Responsibility Agreement
I understand and agree that I will be financially responsible for any and all charges for services. Medications, procedures, or treatments are in
addition to our regular office fee and are due at the time services are rendered. I also understand and agree that it is my responsibility to know
if the provider I am seeing is a contracted and in-network provider with my insurance company or plan.
Consent to Treatment
I hereby consent to evaluation, testing, and treatment as directed by Anna Family Healthcare. I acknowledge that the practice of medicine is
not an exact science and that no guarantees have been made to me as to the outcome of treatment. I grant this consent without duress,
confusion, or pressure from Anna Family Healthcare.
HIPAA Disclosure
I acknowledge that I have received and read a copy of Anna Family Healthcare’s HIPAA notice of privacy policy.
Responsible Party Signature:
Responsible Party Printed Name:
Date:
Pediotric Heolth History
Your child's heolth is of the utmost importonce to us. Pleose f ill out this form os completely ond occurotely os you con.
Tf you ore unsure of how to onswer o certoin item, just circle the item ond we will be hoppy to discuss it with you. All
informotion is treoted conf identiolly.
ha+a'
Child's Nhme:
Dote of Birth:
Age:
Mother's Mme:
Home Phone:
Fother's Nome:
Horne Phone:
Work Phone:
Work Phone:
Child's School:
Grode:
Previous
Physicion:
Subsfonce
Pleose check
City/State:
Phone:
Medicotion Mrne
Reaction
if the child hos ever hod ony of the
Dosoge
following:
Anemio
Asthmo
Murmurs
Poor Appetite
Irregular heort beot
Constipotion
Bronchitis
Difficulfy Breathinq
Broken Bones
Soroins
Coordinotion
Freguent Colds
Problems
Hepotitis
Meosles
Crossed or
Diorrhea
Posture Problems
Excessive Hunger
Poin, weokness
wonderinq
Eye
Mumps
frritotion
Vision Problems
Rheurnotic Fever
Pneumonio
Difficultv Hearinq
Whooping Cough
Eoroches
RSV
Eor
fnfections
Other:
swellinq
Persistent Cough
Nlouseo
Rectal Bleedinc
Stomochoches
Vomitinq
Worms
Depression
Sinus Problems
Dizziness
Sore Throot
Strep Throoi
Foi nti no
Forgeifulness
Heodoches
Bedwettinq
Blood in Urine
Dioper Rosh,
Sensitivity
Hoorseness
Mouth-Breothing
Excessive Thirst
Speech Problems
Bleedinq 6ums
Grindinq Teeth
or
Loss
Tonsil fnfections
Wheezinq
of Sleep
Mood Swinqs
Nervousness
Bruise Eosily
Change in Moles
Numbness
Hives
Persistent
Thumb Sucking
Dischorge
(vagino,/penis)
Lost dental Check
Freguent Urinotion
Sweoting
Brush, how often2
Poinful Urinotion
Tiredness
Floss, how often?
Unusuol Urine Order
UD:
Reoson
Dote
Hospitol, City, Stote
Serious fn iuries/f l lness
Scores
Sores thof won't heol
Dote
Outcome
TH
Mon's oge af
birthl
During preghohcy, which of these condifions did you hove? (Pleose check oll thol dpply)
Alcohol Use
6errnn Measles
Venereol Diseose
Anemio
Hepoiitis
Noh-Prescriplioh drug use:
Hiqh Blood Pressure
Presariptioh druq usel
Diobefes
Prolein in Uaihe
Ederno/Swellinq
Controlled Substonce druq use:
Exposure
to chernicols or
Tobocco U5e
O
ther:
rodiotion
Fever
DELIVERY (PIease circle oll thot opply)i
Oh
Premoiure
Tinre
Norrnol Delivery
C-S€ction
Mme
Aqe
Aqe
Siblinq
Mother
Pleose
circle ony condition thoi ony of the child's blood relotives hove hod ond their reloiiohship:
Alcoholisrn
Allerqies
Kidney Disorder
Anemio
Lunq Disorder
Mentol Diseose/Disorder
Mehtol Retordotion
Musculor Disorder
Rheurlo+ic Fever
SeizurelConvulsions
Asthnd/Emphyserno
BonelJoint Disorders
Conaer
Diobetes
Epilepsy
Eye
or Eor Disorder
Genelac
Stroke
Thyroid Disorder
belecls
Heort Daseose
TB
Hemophilio
Yenereal Diseose
Hiqh Blood Pressure
I
ockhowledg€
Signolure:
ihot the informotion contoined herein
is
correcl io the best of rny knowledqe.
Relqiionship lo polient:
6enerol Health
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
IMMUNIZATION REGISTRY (ImmTrac)
MINOR CONSENT FORM
(Please print clearly)
For Clinic/Office Use
Child’s Last Name
Child’s First Name
/
Child’s Middle Name
/
*Children under 18 years only.
Child’s Gender:
Male
Female
Child’s Date of Birth
Child’s Address
Apartment #
City
State
Zip Code
Mother’s First Name
Mother’s Maiden Name
Telephone
County
ImmTrac, the Texas immunization registry, is a free service of the Texas Department of State Health Services (DSHS). The
immunization registry is a secure and confidential 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, public health departments,
schools and other authorized professionals can access your child’s immunization history to ensure that important vaccines are not missed.
The Texas Department of State Health Services encourages your voluntary participation in the Texas immunization registry.
Consent for Registration of Child and Release of Immunization Records to Authorized Entities
I understand that, by granting the consent below, I am authorizing release of the child’s immunization information to DSHS and I further
understand that DSHS will include this information in the state’s central immunization registry (“ImmTrac”). Once in ImmTrac, the
child’s immunization information may by law be accessed by:
a public health district or local health department, for public health purposes within their areas of jurisdiction;
a physician, or other health-care provider legally authorized to administer vaccines, for treating the child as a patient;
a state agency having legal custody of the child;
a Texas school or child-care facility in which the child is enrolled;
a payor, currently authorized by the Texas Department of Insurance to operate in Texas, regarding coverage for the child.
I understand that I may withdraw this consent to include information on my child in the ImmTrac Registry and my consent to release
information from the Registry at any time by written communication to the Texas Department of State Health Services, ImmTrac Group –
MC 1946, P.O. Box 149347, Austin, Texas 78714-9347.
By my signature below, I GRANT consent for registration. I wish to INCLUDE my child’s information in the Texas
immunization registry.
Parent, legal guardian or managing conservator:
_______________________
Date
________________________________________________________________________
Printed Name
_______________________________________________________________________________________
Signature
Privacy Notification: With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review
the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See http://www.dshs.state.tx.us for more
information on Privacy Notification. (Reference: Government Code, Section 552.021, 552.023, 559.003 and 559.004)
Upon completion, please fax or mail form to the DSHS ImmTrac Group or a registered Health-care provider.
Questions? (800) 252-9152
(512) 776-7284 Fax: (866) 624-0180
www.ImmTrac.com
Texas Department of State Health Services ImmTrac Group – MC 1946 P.O. Box 149347
Austin, TX 78714-9347
Stock No. EC-7
Revised 05/18/2012
PROVIDERS REGISTERED WITH ImmTrac – Please enter client
information in ImmTrac and affirm that consent has been granted.
DO NOT fax to ImmTrac. Retain this form in your client’s record.