Patient Forms

Patient forms now available online!

As a convenience to our patients, Tepeyac Family Center offers the following registration and update forms on-line. They are designed for you to print them, complete them, and bring them with you at your next appointment. This allows you to be prepared for your appointment when you arrive at the practice.

If you are a new patient, please fill out:
      New Patient Registration Form
      Privacy Notice Form
      HIPAA Release Form
      Health History Questionnaire Form

If you are have an appointment for your annual examination, then please complete:

Annual Medical Survey

New Patient Registration Form (if any updates are required)

If you need to request your records from a previous doctor:
Medical Release Form TO Tepeyac

Please put your previous doctor's information in the blank spaces so that we may fax over the request.

To request your records if you are leaving the practice:
Medical Release Form FROM Tepeyac

If you are a current patient and have not updated your personal information since May 2005, please download:
Patient Registration Form
HIPAA Release Form

If you are newly pregnant:
Health History Questionnaire Form
OB Family History and Genetic Screening Form

If you have a change in address:
Address Update Form

If you are requesting the practice complete disability claim forms, please complete you portion of the form, mail it to us, Attn: Nursing Staff. There will be a $25.00 charge for each use of this service payable prior to releasing the form to you.

If you have a change in insurance:
Insurance Update Form

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