Forms

• New Patient Registration Packet

• Update Contacts Page Only

Contacts Form (UPDATE) - Giving Authority to Bring Patient

• Medical Power of Attorney Form

This form will be required for any legal guardian who wishes someone other than a previously authorized individual to accompany a child to his/her appointment.

• Private Pay Agreement

• Notice of Privacy Practices

• Aviso de Prácticas de Privacidad

• Notice of Privacy Practices Acknowledgement

• Medical Power of Attorney Form

• Medical Release Form

• Medical Release Shot Record Form

• TTU_HL_consents-new

Texas Tech Medical Records Release

• HL_Consent-to-Treat-English-Spanish

Texas Tech Consent to Treat

• Immunization Schedule for MPA 2023

• Patient COVID Fact Sheet (SARS)

• Patient COVID Fact Sheet - Quick View (SARS)

• VAXCARE Accepted Insurance List

Vaxcare is our vaccine vendor who bills for the vaccines MPA administers.

• First Aid for Children

• First Aid for the Choking Infant

• Car safety form

• Calcium Content Form

• Shoe Selection

• ADHD Parent Initial Form

• ADHD Parent Follow-Up Form

• ADHD Teacher Initial Form

• ADHD Teacher Follow-Up Form

• GAD-7

• SCARED Anxiety Screen (child to complete)

• SCARED Anxiety Screen (parents to complete)

• MCHAT

• PSC-17