New Patient


    Patient’s First Name

    Patient’s Last Name

    Date of Birth





    Zip Code

    Phone Number


    First Name

    Last Name

    Date of birth





    Zip Code

    Phone Number

    Email Id

    Emergency Contact

    First Name

    Last Name




    Zip Code

    Phone Number

    Email Id

    Insurance Information

    Name of Insurance

    Subscriber No.

    Group No.

    Name of Insured

    Relationship to Patient

    Pharmacy Information

    Name of Pharmacy

    Pharmacy Phone Number

    Pharmacy Address



    Zip Code

    Medical History

    Birth Weight

    Birth Length

    Gestational Age


    Pregnancy complications, if any

    Delivery method

    Developmental History

    Previous Surgeries

    Previous Hospitalizations


    Current Medications

    Family History

    Reason for Visit

    Does your child have, or has he/she had any of the following


    Anemia -

    Asthma -

    Blood Disorder -

    Chest Pain -

    Convulsions/Seizures -

    Diabetes -

    Drug Addition -

    Excessive Bleeding -

    Excessive Thirst -

    Fainting Spells/Dizziness -

    Frequent/Chronic Cough -

    Frequent Headaches -

    Heart Murmur -

    Heart Problems -

    Hemophilia -

    Hepatitis A, B, C -

    High Blood Pressure -

    Kidney Problems -

    Lung Diseases -

    Psychiatric Problems -

    Scarlet Disease -

    Tumors or Growths -

    Ulcers -

    Veneral Disease -

    Weight Loss -

    Other problems not mentioned above -

    Authorization To Consent To Treatment Of A Minor

    I, the undersigned, Parent/Legal guardian of ,
    a minor, do hereby authorize the medical staff of Dr. Anita Jacob as agent(s) for the undersigned to consent
    to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is
    deemed advisable by, and is deemed advisable by, and is rendered under the general or special supervision of,
    any physician and surgeon licensed under the provisions of the Medical Practice Act on the medical staff of
    any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said

    It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care
    being required but is given to provide authority and power on the part of our aforesaid agent(s) to give
    specific consent to any and all such diagnosis, treatment or hospital care which aforementioned physician(s)
    in the exercise his/her best judgment may deem advisable.
    These authorizations shall remain effective unless revoked in writhing and delivered to said agent(s) or until
    minor reaches 18 years of age.

    Medicaid Client Acknowledgment Statement

    I understand that, in the opinion of Dr. Anita Jacob, the services or items that I have requested to be provided to me may not be covered under the Texas Medical Assistance Program as being reasonable and medically necessary for my care. I understand that the Texas Department of Health or its health insuring agent determines the medical necessity of the services or items that I request and receive. I also understand that I am responsible for the payment of the services or items requested and received if these services or items are determined not to be reasonable and medically necessary for my care

    Notice Of Privacy Practices

    Our Legal Duties: Law requires us to:

    • Keep your medical information private.
    • Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical information.
    • Follow the terms of the current notice.

    We Have the Right to:

    • Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
    • Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

    Use And Disclosure Of Your Medical Information

    The following section describes different ways that we use and disclose medical information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below. Without your specific written authorization you provide may be revoked at any time by written to us.

    For treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about to doctors, nurses , technicians, medical students, or other people who are taking care of you. We may also share medical information about you to your other health care provides to assist them in treating you.

    For payment: We may use and disclose your medical information for payment purposes. A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include your medical information.

    For Health Care Operations: We may use and disclose your medical information for our health care operations. This might include measuring and providing quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

    Additional Uses and Disclosures: WIn addition to using and disclosing your medical information for treatment, payment, and health care operations, we may use and disclose medical information for the following purposes.

    Facility Directory: Unless you notify us that you object, the following medical information about you will be placed in our facility directories: your name; your location in our facility; your condition described in general terms; your religious affiliation, if any. We may disclose this information to members of the clergy, or except for your religious affiliation, to others who contact us and ask for information about you by name.

    Notification: We may use and disclose medical information to notify or help notify: a family member, your personal representative or another person responsible for your care. We will share information about your location, general condition, or death. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information for you.

    Disaster Relief: We may share medical information with a public or private organization or person who can legally assist in disaster relief efforts.

    Fundraising: We may provide medical information to one of our affiliated fundraising foundations to contact you for fundraising purposes. We will limit our use and sharing to information that describes you in general, not personal, terms and the dates of your health care. In any fundraising materials, we will provide you a description of how you may choose not to receive future fundraising communications.

    Research in Limited Circumstances: We may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of medical information.

    Funeral Director, Medical Examiner: To help them carry out their duties, we may share the medical information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

    Specialized Government Functions: Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.

    Court Orders and Judicial and Administrative Proceedings: We may disclose medical information in response to a court or administrative order, subpoena discovery request, or other lawful process, under certain circumstances. Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcements officials. We may share limited information with a law enforcement official concerning the medical information of a suspect, fugitive, material witness, crime victim or missing person. We may share the medical information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.

    Public Health Activities: As required by law, we may disclose your medical information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect. We may also disclose your medical information to persons subject to jurisdiction of the Food and Drug Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration. We may also, when we are authorized by law to dos so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

    Victims of Abuse, Neglect, or Domestic Violence: We may use and disclose medical information to
    appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic
    violence or the possible victim of other crimes. We may share your medical information if is necessary to
    prevent a serious threat to your health or safety or the health or safety of others. We may share your medical
    information if necessary to help law enforcement officials capture a person who has admitted to being part of
    a crime or has escaped from legal custody.

    Workers Compensation: We may disclose health information when authorized or necessary to comply with
    laws relating to workers compensation or other similar programs.

    Health Oversight Activities: We may disclose medical information to an agency providing health oversight
    activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings,
    inspections, licensure or disciplinary actions, or other authorized activities.

    Law Enforcement: AUnder certain circumstances, we may disclose health information to law enforcement
    official. These circumstances include reporting required by certain laws (such as the reporting of certain types
    of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning
    identification and location at the request of a law enforcement official, reports regarding suspect victims of
    crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in

    Appointment reminder: We may use and disclose medical information for purposes of sending you
    appointment postcards or otherwise reminding you of your appointWe may use and disclose medical information to furnish you
    with information about health-related benefits and services that be of interest to you and to describe or
    recommend treatment alternatives

    1. Look at or get copies of certain parts of your medical information. You may request that we provide
      copies in a format other that photocopies. We will use the format you request unless is not practical
      for us to do so. You must make your request in writing. You may ask the receptionist for the form
      needed to request access. There may be charges for copying and for postage if you want the copies
      mailed to you. Ask the receptionist about our fee structure.
    2. Receive a list of all the times we or our business associates shared your medical information for
      purposes other than treatment payment, and health care operations and other specified exceptions.
    3. Request that we place additional restrictions on our use or disclosure of your medical information. We
      are not required to agree to these additional restrictions, but if we do, we will abide by our agreement.
      (except in the case of an emergency)
    4. Request that we communicate with you about your medical information by different means or to
      different locations. You request that we communicate your medical information to you by different
      means or at different locations must be made in writing to our Privacy Officer.
    5. Request that we change certain parts of your medical information. We may deny your request if we
      did not create the information you want changed or for certain other reasons. If we deny your request,
      we will provide you with a written explanation. You may respond with a statement of disagreement
      that will be added to the information you wanted changed. If we accept your request to change the
      information, we will make reasonable efforts to tell others, including people you name, of the change
      and to include the changes in any future sharing of that information
    6. If you wish to receive a paper copy of this privacy notice, then you have the right to obtain a paper
      copy by making a request in writing to our Privacy Officer

    Questions and Complaints

    If you have any questions about this notice, please ask the receptionist to speak to our Privacy Officer. If you
    think that we may have violated your privacy rights, you may speak to our Privacy Officer and submit a
    written complaint. To take either action, please inform the receptionist that you wish to contact the Privacy
    Officer or request a complaint form. You may submit a written complaint to the U.S Department of Health
    and Human Services, we will provide you with the address to file your complaint. We will not retaliate in any
    way if you choose to file a complaint

    Signature Parent/Guardian

    Your medical home for comprehensive pediatric primary care. Let's together build a healther community.

    Emergency Services