New Pediatric Patient History Intake

Please correct the errors described below.

To our new patients: Welcome to NW Pediatrics and Family Medicine, PLLC. To help us establish you with our practice, please provide us with your complete health history: body, mind, and spirit.

Personal History






Add allergy

Current Medications

Add current medication

Current Herbs / Vitamins/ Supplements

Add current herb/ vitamin/ supplement


Birth History:

Past Medical History:


List prior illness, injury, hospitalization, surgery, and/or trauma:

Add condition

Social History:



Family History:

List Siblings:

Add sibling

Has any blood relative ever had the following:



(When guardian is unable to be reached)

List 3 contacts:

Add emergency contact

This history record has been designed to facilitate our patients continuity of care at NW Pediatrics and Family Medicine, PLLC. This is a confidential record and will be kept in this facility. Information contained here will not be released to anyone without your authorization to do so.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


Clinics and hospitals are unable to treat or care for minors (children) without consent from parents or legal guardians. If a child has a medical emergency when parents or legal guardians are not readily available to provide consent, then problems can occur. Complete this form and leave it with the person who is responsible for your child in your absence. In case of a medical emergency, this form must be brought with the child to the clinic or hospital.

authorize and consent to medical, surgical and hospital care, treatment and procedures to be performed by a licensed physician or hospital when, in the sole discretion of the attending physician, such care, treatment and procedures are immediately necessary or advisable in the interest of my child’s health and well-being.

Under the circumstances set forth above, I elect not to be informed in advance of the nature and character of the proposed treatment, its anticipated results, possible alternatives, and the risks, complications, and anticipated benefits involved in the proposed treatment and the alternative forms of treatment, including non-treatment.

Provided that proper photo identification and this written notice is presented, the following individual(s) are authorized to bring the aforementioned minor child to clinic visits.

Add authorized individual

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.





The Federal Health Insurance Portability and Accountability Act (HIPAA) laws are written to protect the confidentiality of your Health Information. The following notice details the policies and procedures that are used to ensure that your Health Information is not shared with anyone who does not require it. It also describes your rights to access and control your Health Information. “Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health services.

We will use and communicate your Health Information only for the purposes of providing treatment, obtaining payment and conducting health care operations. Your Health Information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

How your Health Information may be used:

To Provide Treatment

We will use your Health Information within our office to provide you with the best health care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between your provider, nurses, medical technicians, and business office staff. In addition, we may share your Health Information with other providers, referring providers, clinical and imaging laboratories, pharmacies or other health care personnel providing you treatment.

To Obtain Payment

Your Health Information may be used with an invoice to collect payment for treatment that you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will only work with companies with a similar commitment to the security of your Health Information.

To Conduct Health Care Operations

We may use or disclose, as needed, your Health Information in order to support the business activities of this practice. These activities include, but are not limited to, quality assessment activities, employee performance evaluations, training for medical students, licensing, and conducting or arranging for other business activities. We may use a sign-in sheet at the registration desk for you to write your name and indicate the nature of your visit. We may call your name in the waiting room when your provider is ready to see you. We may use or disclose your Health Information, as necessary, to contact you to remind you of your appointment.

Disclosure of Your Health Information

We may use or disclose your Health Information in the following situations without your authorization. These situations include:

  • Abuse, neglect, or domestic violence — Government authorities will be notified only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law, or with your agreement.
  • Public health and national security — Federal officials or military authorities may require your Health Information to complete an investigation related to public health or to national security. Health Information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.
  • For Law Enforcement—As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limiting circumstances, if you are a victim of a crime or in order to report a crime.
  • Family, Friends and Caregivers—With your permission, we may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. In an emergency when you are unable to tell us what you want, we will use our best judgment when sharing your Health Information only when it will be important to those participating in providing your care.

Other than stated above, or where Federal, State, or Local law requires us, we will not disclose your Health Information other than with your written authorization. You may revoke that authorization at any time, except to the extent that your provider or the provider’s practice has taken an action on the use or disclosure indicated in the authorization.

Your Rights

The following is a statement of your rights with respect to your Health Information:

  • Restrictions—You have the right to request a restriction of your Health Information. Your request must state the specific part of your Health Information to be restricted and to whom you want the restriction to apply. Your provider is not required to agree to a restriction that you may request, particularly if your provider believes that it is in your best interest to permit use and disclosure of your Health Information.
  • Confidential Communications—You have the right to request to receive confidential communication from us be alternative means or at an alternative location; for example, through sealed mail, or with no family members present. We will make every effort to honor your reasonable requests for confidential communications.
  • Inspect and Copy Your Health Information—You have the right to inspect and copy your Health Information, including your complete chart, imaging records and billing records. Under Federal law, however, you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable anticipation, or use in, a civil, criminal, or administrative action or proceeding, and Health Information that is subject to law that prohibits access to Health Information. Let us know if you would like a copy of your Health Information. There may be a reasonable fee to duplicate and assemble your copy.
  • Amend Your Health Information—You have the right to ask us to amend your records if you believe your Health Information records are incorrect or incomplete. We will be happy to accommodate you as long as our office created and maintains this information. Please provide your request in writing and describe your reason for the change. If we deny your request, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
  • Documentation of Health Information—You have the right to ask us for a description of how and where your Health Information was used by our office for any reason other than for treatment, payment or health operations. Please let us know in writing the period for which you are interested. There may be a reasonable fee for your request.
  • Request a Paper Copy of this Notice—You have the right to obtain a copy of this notice of Health Information Privacy Practices.

We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of the notice and will inform you by mail of any changes.

You have the right to complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. Please let us know of your concerns or complaints in writing. We will not retaliate against you for filing a complaint.

Patient Acknowledgment

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Written Acknowledgment of Receipt of NW Cypress Pediatrics and Family Medicine, PLLC


General Consent to Treat


This Facility has on staff an advanced practice nurse of assist in the delivery of medical care. An advanced practice is not a doctor. An advanced practice nurse is a registered nurse who has received advanced education and training in the provision of health care. An advanced practice nurse can diagnose, treat, and monitor common acute and chronic diseases as well as provide health maintenance care. In Addition, the advanced practice nurse may treat minor lacerations and other minor injuries.

I have read the above, and hereby consent to the services of an advanced practice nurse for my health care needs.

I understand that at any time I can refuse to see the advanced practice nurse and request to see a physician if a physician is available.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Electronic Medical Records and Electronic Prescriptions

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Thank you for choosing NW Cypress Pediatrics and Family Medicine. We realize you have a choice in selecting healthcare and we are honored you have chosen us. Our staff is committed to providing our patients with the highest quality of care possible. In doing so, we would like to provide you with information regarding our office policies


Our providers participate with many health plans and as a courtesy to our patients, we file claims with these companies. It is ultimately your responsibility for the full and timely payment of your account.

Check In

Our providers participate with many health plans and as a courtesy to our patients, we file claims with these companies. It is ultimately your responsibility for the full and timely payment of your account.

  • Current Insurance Card. Make sure your PCP is an NW Cypress Pediatrics and Family Medicine provider.
  • Current Photo Identification
  • Update to contact information such as home address, phone numbers, contact information, email address, employer information, etc.
  • Current Immunization records (for new patients and check ups)
  • Necessary documents for the visit (ex hospital discharge summary, urgent care paperwork, labwork results, guardianship papers, etc)

Verification of Benefits

We will attempt to verify coverage and benefits prior to your visit. If we are unable to obtain a verification of coverage, you may be asked to pay in full or reschedule your visit for a time the verification can be obtained. This verification will be used to estimate your financial responsibility; however, this verification is not a guarantee by your health plan to pay for services received.

Payment of Patient Responsibility

Payment of your estimated patient responsibility is expected at the time services are rendered. This payment will include known deductibles, copays, and coinsurance amounts applicable for each visit and or procedure. While we may estimate your financial responsibility, it is your insurance company that makes the final determination regarding eligibility and benefits. For your convenience we accept cash, checks, most major credit cards and debit cards. You will be responsible for payments not received by your insurance

NSF Checks/Denied Credit Card Payments

You will be charged a $25.00 fee should a payment be returned for insufficient funds. This fee applies to payments made at our front desk, mailed in to the Business Office, electronically via the internet, or payments by phone.

Past Due Amounts

In the event your account becomes past due, and all efforts to collect payment have failed, your account may be referred to a collection agency.

Additional Services Identified During Treatment

Please be aware additional charges may be incurred if during the course of a physical exam a physician addresses, diagnoses, or treats problem-focused health concerns unknown at time of check in.

Non Covered Services

Please be aware certain office procedures or services may not be covered, or may be considered “not medically necessary”, “experimental”, “cosmetic”, or simply “non-covered” by your health plan. You are responsible for payment of these services. In the event your care exceeds a plan limitation, you will be responsible for the balance. It is your responsibility to know the benefits and limitations of your current health care coverage. This clinic will provide medically necessary care based on patient’s needs, not a patient’s insurance coverage. This clinic is not responsible for knowing your plant’s specific benefit and coverage limitations.

Appointment Scheduling

Please be advised, as a courtesy, an automated service will call the primary phone number and email listed on file to remind you of your appointment date and time. You must notify the office within 24 hours of your scheduled appointment if you are unable to keep your appointment. Failure to notify the office within 24 hours may result in a $25.00 assessment to your account. Repeated failure to call and cancel your scheduled appointment without the proper 24 hour notice may result in your dismissal as a patient. Please notify the office immediately for any changes to how your would like to be contacted.

Forms/Medical Letters

We are happy to assist you by completing forms and generating medical letters for you upon your request. The fee for this service varies depending on the form or letter, but most do not exceed $25.00 per form. Payment is collected when you pick up the documents. Please allow 10 business days.

Medical Records

Requests for your medical records must be in writing via a special release form. Release of records is managed via an outside vendor. The cost is $25.00 for the 1st 20 pages and $.50 for each additional page. You will pay the outside vendor for these copies.

Office Hours

While appointment times vary for each provider, our office staff is available by telephone during regular business hours. Because our providers and nurses are often tending to patients, it is typically necessary for you to leave a message. So we may assist you in a timely manner, please leave pertinent information to include the reason for your call and best number to call. We have an answering service to take your calls before and after our scheduled office hours.

  • Emergency Needs – always call 911
  • Prescription Refills – call during regular office hours and if leaving a message, provide your name, the medication, your pharmacy name, location, and phone number. Refills of controlled substances and/or narcotics MUST be filled by speaking with a medical staff member. You might need to schedule an appointement for refills depending on the nature of the refill.
  • After Hours- please call 281-469-7400 to schedule telemedicine visit.

Authorization to Release Information

I hereby authorize NW Cypress Pediatrics and Family Medicine to: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of an examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of a lifetime. This order will remain in effect until revoked in writing.

Assignment of Benefits

I hereby assign all medical benefits to include major medical benefits to which I am entitled. I hereby authorize and direct insurance carrier(s), include Medicare, Medicaid, private insurance and any other health/medical plan, to issue payment check(s) directly to NW Cypress Pediatrics and Family Medicine for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.

Financial Responsibility

I acknowledge I have requested medical services from NW Cypress Pediatrics and Family Medicine, on behalf of myself and/or my dependents and understand that by making this request I become fully financially responsible for any and all charges incurred in the course of the treatment authorized.

I agree to pay NW Cypress Pediatrics and Family Medicine for all services and products administered. I understand and acknowledge that any monies collected prior to the date services are rendered or products are administered will be applied as a deposit towards total charges assessed for the services rendered. The deposit shall not be considered payment in full. If I participate in a managed care plan, such as an HMO or PPO, I promise to pay for any services or products administered that are not covered under the plan as a result of inaccurate, incomplete or untimely patient information provided by me to the clinic and for any out-of-network charges.

For telemedicine services, a $50 charge will be made at the time of scheduling. We will file a claim with your insurance. If your insurance covers the visit, the balance will be credited to your account. If your insurance does not cover the visit, the $50 will pay for the telemedicine visit.

I further understand that fees are due and payable on the date the services are rendered and agree to pay all such charges incurred in full immediately upon presentation of the appropriate statement. A photocopy of this assignment is to be considered as valid as the original.

My signature certifies I have read and understand the above content of this document.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


*Children under 18 years only

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.

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 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 *

Texas Department of State Health Services * ImmTrac Group — MC 1946 * P. O. Box 149347 * Austin, TX 78714-9347

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.

Texas Vaccines for Children (TVFC) Program

Patient Eligibility Screening Record

A record of all children 18 years of age or younger who receive immunizations through the Texas Vaccines for Children (TVFC) Program must be kept in the health care provider’s office for a minimum of five (5) years. The record may be completed by the parent, guardian, individual of record, or by the health care provider. TVFC eligibility screening and documentation of eligibility status must take place with each immunization visit to ensure eligibility status for the program. While verification of responses is not required, it is necessary to retain this or a similar record for each child receiving vaccines under the TVFC Program.

1. Child's Name:

3. Parent, Guardian, or Individual of Record:

4. Primary Provider’s Name:

5. To determine if a child (0 through 18 years of age) is eligible to receive federal vaccine through the TVFC Program, at each immunization encounter or visit, enter the date and mark the appropriate eligibility category. If Column A - F is marked, the child is eligible for the TVFC Program. If column G is marked the child is not eligible for federal VFC vaccine.

Add date and appropriate eligibility category

* Underinsured includes children with health insurance that does not include vaccines or only covers specific vaccine types. Children are only eligible for vaccines that are not covered by insurance. In addition, to receive VFC vaccine, underinsured children must be vaccinated through a Federally Qualified Health Center (FQHC), a Rural Health Clinic (RHC), or under an approved deputized provider. The deputized provider must have a written agreement with an FQHC or an RHC and the state, local, or territorial immunization program in order to vaccinate underinsured children.

** Other underinsured are children that are underinsured but are not eligible to receive federal vaccine through the TVFC Program because the provider or facility is not an FQHC or an RHC, or a deputized provider. However, these children may be served if vaccines are provided by the state program to cover these non-TVFC-eligible children.

*** Children enrolled in the State of Texas Children’s Health Insurance Program (CHIP). An agreement between the DSHS Immunization Unit and CHIP stipulates that vaccines for eligible CHIP enrollees are purchased through the federal contract.



Private Insurance:

Programa de Vacunas para los Niños de Texas

Registro de la determinación de elegibilidad del paciente

En el consultorio del proveedor de servicios de salud debe mantenerse, durante un mínimo de cinco (5) años, un registro de todos los niños de 18 años de edad o menores que reciban inmunizaciones por medio del Programa de Vacunas para los Niños de Texas (TVFC). Dicho registro lo puede rellenar el padre o la madre, el tutor, el individuo cuyo nombre aparece en el registro, o el proveedor de servicios de salud. En cada visita para inmunización debe determinarse y documentarse el estado de elegibilidad para el TVFC a fin de asegurar que el menor es elegible para el programa. Aunque no se requiere la verificación de las respuestas, es necesario conservar este registro, o uno similar, para cada niño que reciba vacunas bajo el Programa TVFC.

1. Nombre del menor:

3. Padre, tutor o individuo del registro:

4. Nombre del proveedor primario:

5. Para determinar si un menor (de 0 a 18 años de edad) es elegible para recibir vacunas federales por medio del Programa TVFC, en cada cita o visita para inmunización anote la fecha y marque la categoría de elegibilidad apropiada. Si marca una columna de la A a la F, el menor es elegible para el Programa TVFC. Si marca la columna G, el menor no es elegible para las vacunas federales VFC.

Agregar fecha y categoría de elegibilidad apropiada

* El seguro insuficiente incluye a los niños cuyo seguro médico no incluye vacunas o solo cubre ciertos tipos específicos de vacunas. Los niños solo son elegibles para recibir vacunas que no están cubiertas por el seguro. Además, para recibir las vacunas de VFC, los niños con seguro insuficiente deben ser vacunados en un Centro de Salud Federalmente Acreditado (FQHC), en una Clínica de Salud Rural (RHC), o por un proveedor delegado autorizado. El proveedor delegado debe tener un contrato por escrito con un FQHC o una RHC y con el programa de inmunización estatal, local o territorial para poder vacunar a los niños con seguro insuficiente.

** Otros niños con seguro insuficiente son aquellos que, aunque están insuficientemente asegurados, no son elegibles para recibir las vacunas federales por medio del Programa TVFC porque el proveedor o centro no es un FQHC, o una RHC, o un proveedor delegado. Sin embargo, estos niños pueden ser atendidos si las vacunas son proporcionadas por el programa estatal para dar cobertura a los niños que no son elegibles para el TVFC.

*** Niños inscritos en el programa estatal separado CHIP (Children’s Health Insurance Program). Estos niños se consideran asegurados y no son elegibles para recibir vacunas mediante el Programa VFC. Cada estado proporciona orientación específica sobre cómo se adquieren y administran las vacunas del CHIP a través de los proveedores participantes.



Seguro privado:

Telemedicine Consent Form

Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.

1. Nature of telemedicine services. During the telemedicine consultation:

  • This is a live 2 way audio and video involving the use of electronic communications to enable health care providers to continue to provide medical care
  • Details of your medical history, examinations, lab, diagnostic results and any other necessary medical problems may be discussed as in a regular visit

2. Expected Benefits:

  • Improved access to medical care by enabling patient to remain at his/her remote site while
  • Avoid urgent cares and emergency room if not needed
  • Access health care 24 hours a day, 7 days a week.

1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.

2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room.

3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.

  • If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.

4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.

  • I may revoke my right at any time by contacting NW Cypress Pediatrics and Family Medicine at 281-469-7400.

5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services.

6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.

  • I understand that my insurance carrier will have access to my medical records for quality review/audit.
  • I understand that I will be responsible for any out-of-pocket costs such as copayments or coinsurances that apply to my telemedicine visit.
  • I understand that health plan payment policies for telemedicine visits may be different from policies for in-person visits.

7. I understand that this document will become a part of my medical record.

By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language 1 understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.