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Patient Forms

Complete forms online before your visit — or download and print.

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Complete your paperwork online before you arrive — no clipboard, no waiting room delays.

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Online

Complete and sign these forms electronically. They'll be sent directly to our office.

New Patient Registration

Demographics, insurance, medical history, medications, and consent to treat. Required for all new patients.

~3–5 min

HIPAA Privacy Acknowledgment

Acknowledge receipt of our Notice of Privacy Practices as required by federal law.

~2 min

Medical Records Release

Authorize transfer of your medical records to or from another provider.

~5 min

Financial Policy

Review and sign our financial responsibility, assignment of benefits, and authorization to release information.

~3 min

MHiE Consent (English)

Memorial Hermann Information Exchange — consent for electronic sharing of health information with participating providers.

~2 min

MHiE Consent (Spanish)

Consentimiento de Intercambio de Información de Memorial Hermann — autorización para compartir información de salud.

~2 min

Download & Print

PDF

These documents are available as PDF files you can download, print, and bring to your visit.

HIPAA Privacy Statement (English)

Our complete Notice of Privacy Practices document.

PDF

HIPAA Privacy Statement (Spanish)

Aviso de Prácticas de Privacidad.

PDF

MHiE Consent Form (English)

Memorial Hermann Information Exchange consent form — printable version.

PDF

MHiE Consent Form (Spanish)

Formulario de consentimiento de intercambio de información de Memorial Hermann — versión imprimible.

PDF

Disability Parking Placard Application

Texas application for persons with disabilities parking placard and/or license plate. Requires physician signature.

PDF

Out-of-Hospital DNR (English)

Texas Out-of-Hospital Do-Not-Resuscitate order form.

PDF

Out-of-Hospital DNR (Spanish)

Formulario de Orden de No Resucitar Fuera del Hospital de Texas.

PDF

MetroLift Application

Houston METRO paratransit application for patients who need accessible transportation.

PDF

Need help with a form? Call us at 713-533-1700 and our staff will be happy to assist you.