Patient Forms
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 to your next appointment. This allows you to be prepared for your appointment when you arrive at the practice.
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NEW PATIENT FORMS
If you are a NEW patient: You will need to complete these forms in addition to any of the forms below which relate to specific appointment purposes.
New Patient Registration Form (this is both for new patients and curent patients if you have had a change in your medical information)
Privacy Notice Form
HIPAA Release Form
Health History Questionnaire Form
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CURRENT PATIENT FORMS
If you are a CURRENT patient but need to update your medical history form…
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SPECIFIC APPOINTMENT-RELATED FORMS:
If you have an appointment for your annual examination
If you have an appointment for an infertility related consultation
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MISCELLANEOUS FORMS:
You will need to complete these forms in addition to any of the other forms below which relate to specific appointment purposes.
If you are requesting your medical records FROM a previous doctor TO Tepeyac
If you are requesting your medical records to be transferred TO another practice FROM Tepeyac
If you are requesting the practice to complete disability claim forms
If you have a change in insurance
If you have a change in address
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If you are newly pregnant, please fill out:
Health History Questionnaire Form
OB Family History and Genetic Screening Form
If you are a new patient, complete the new patient forms.
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If you have an appointment for your annual examination, please complete:
New Patient Registration Form (if any updates are required)
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If you have an appointment for an infertility-related consultation, please fill out:
Preconception counseling survey*
If you are a new patient, complete the new patient forms.
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*Note, unlike the other forms, this form needs to be transmitted to Tepeyac for processing at least a week prior to the appointment. This will ensure that proper insurance coverage will be provided at the time of the appointment. You may:
- email the completed form to: (the subject line should be: New Appointment – Attn: Julie or Allyson) or
- FAX it to (703) 273-9445 (attn: Julie or Allyson) or
- mail it to:
Tepeyac Family Center
11135 Lee Highway
Fairfax, VA 22030.
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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.
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If you are requesting your medical records to be transferred TO another practice:
Medical Release Form FROM Tepeyac to another practice.
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If you are a current patient and have not updated your personal information since May 2005, please download:
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If you are requesting the practice to complete disability claim forms, please complete your portion of the form and mail it to us:
Tepeyac Family Center
11135 Lee Highway
Fairfax, VA 22030.
There will be a $25.00 charge for each use of this service payable prior to releasing the form to you.
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If you have a change in insurance:
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If you have a change in address:
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