Submissions

Email: To submit the forms online, please complete the forms accordingly and email them to: ataher@aol.com

Fax: To Fax the forms, you will need to complete the form and fax it to: 713-796-9302.

Print: You can also complete the form, print it, and bring it with you during your next visit to the center.

Form Descriptions

Authorization Form – Standard Form for patient health information disclosure.
Demographic Form – Patient registration information
Patient History Form – Patient Medical History
Privacy Notice Form – Standard Privacy Notice