Please complete the information below and submit the form online.
This form contains confidential information and is delivered to your doctor through a secure Internet connection.
If you prefer, print out the form after full or partial completion. Bring it with you when you come to our office for your appointment.
If you would like your records from your previous office, please complete this form and Email us firstname.lastname@example.org or Fax 281-476-7062 the release form so we can get your records prior to your appointment.