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Lewisville: Park Lane Village, 502 S. Old Orchard Lane, #126, Lewisville, TX 75067 | 972-436-7962
Central Elementary School: 400 High School Drive, Lewisville, TX 75057

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Patient Forms

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Patient Forms

New Patient Forms - English

Notice of Privacy Practices
PDF, 330.57 KB
Telehealth Acknowledgement Form English
PDF, 190.41 KB
Late Policy
PDF, 117.80 KB
Income Form
PDF, 81.33 KB
Patient Survey
PDF, 100.97 KB
Consent to Medical Treatment of a Minor
PDF, 111.60 KB
Communication Authorization for Personal Health Information
PDF, 134.59 KB
New Patient Registration
PDF, 107.09 KB
Authorization to Release Medical Records and Protected Health Information
PDF, 317.74 KB
Medical History
PDF, 83.49 KB

Español

Consentimiento para Participar en el Servicio de Salud Telemedicina
PDF, 188.62 KB
Notificación de Privacidad
PDF, 221.21 KB
Forma De Ingresos
PDF, 80.93 KB
Encuesta de PediPlace
PDF, 93.29 KB
Poliza Tardia
PDF, 40.34 KB
Autorizacion para Communicar Informacion de Salud Personal
PDF, 133.81 KB
Autorizacion para el Tratamiento de un Menor
PDF, 110.87 KB
Registro de Paciente
PDF, 106.04 KB
Autorizacion para Ortorgar Archivos Medicos e Informacion de Salud Protegida
PDF, 313.58 KB
Historial Medico del Paciente
PDF, 94.52 KB

Locations

Lewisville Location
Park Lane Village
502 S. Old Orchard Lane,
Suite 126
Lewisville, TX 75067
Tel: 972-436-7962
Email: info@pediplace.org

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