10100 Loop 40 West
Midland, TX 79706​
Mailing Address
PO Box 61880
Midland, Tx 79711-1880
Patient Forms
Save time on your first visit by getting some paperwork out of the way ahead of time. Download and print out the forms below.
Then, fill in the blanks and bring them with you to your first appointment
Please be advised that by using these forms, we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into these forms. Online communication is not intended for acute, emergency, or life-threatening health conditions. If you believe you are having a health emergency, contact 911 or go to your nearest emergency department.
Patient Registration Form
Patient History Sheet
Family History Sheet
Permission to Release Health Information
Medical Records Release Form
.
Notice of Privacy Practices
You might need the Adobe Reader to use these files.
If you need to download it, click here.
Patient Demographics Form Download by clicking here.
(for new patients)
Patient Medical History Sheet Download by clicking here.
(for new patients)
Patient Medications Download by clicking here
(for new patients)
Family History Sheet Download by clicking here.
(for new patients)
Permission to Release Health Information Download by clicking here.
(for new patients)
Medical Records Release Form Download by clicking here.
.
Notice of Privacy Practices Download by clicking here.
You might need the Adobe Reader to use these files.
If you need to download it, click here.
Serving the Midland, Odessa, Pecos & Ft Stockton, TX Areas
Proudly Serving Midland, Odessa, Ft. Stockton, and Pecos
• CSR • Diabetic Retinopathy •
* We are located down the street from Midland International Air and Space Port,
next door (west) to the Post Office.
* For Life-Threatening Emergencies, Call 911