Forms
Please review all forms listed below and fill out accordingly.
ATTENTION ALL NEW PATIENTS... the forms below must be filled out prior to being seen by the doctor.
ADULT NEW PATIENT FORM
CHILD NEW PATIENT FORM
Please click on form to download then print and fill out form. Bring completed form(s) with you at the time of your visit.
HEALTH HISTORY FORM
All patients must fill out a Health History Form.
Please click on form to download then print and fill out form. Bring completed form with you at the time of your visit.
INSURANCE INFORMATION FORM
All patients with ANY TYPE of insurance must fill out an Insurance Information Form.
Please click on form to download then print and fill out form. Bring completed form with you at the time of your visit.
ATTENTION ALL MEDICAID PATIENTS... both forms listed below must be filled out.
TEXAS MEDICAL ASSISTANCE PROGRAM AGREEMENT AND UNDERSTANDING FORM
MEDICARE REGULATIONS REQUIRMENT FORM
Please click on form to download then print and fill out form. Bring completed forms with you at the time of your visit.
DIZZINESS QUESTIONNAIRE
Patients experiencing signs of dizziness must fill out a Dizziness Questionnaire. Please click on questionnaire to download then print and fill it out. Bring completed questionnaire with you at the time of your visit.
HEARING PROBLEMS QUESTIONNAIRE
Patients experiencing hearing problems must fill out a Hearing Problems Questionnaire. Please click on questionnaire to download then print and fill it out. Bring completed questionnaire with you at the time of your visit.
MEDICARE PATIENTS WITH HEARING PROBLEMS FORM (ABN)
All medicaid patients who are experiencing hearing problems must fill out this form. Please click on form to download then print and fill out form. Bring completed form with you at the time of your visit.
If you have any questions in regards to any of these forms please call (432) 683-1856. You must have Adobe Acrobat Reader to download forms. You can obtain a free version at http://get.adobe.com/reader/.
Dr. Roger Traxel © 2009 All Rights Reserved |
