NEW PATIENT INTAKE PACKET
Thank you for your interest in our clinic. During your first
visit, you’ll be required to supply us with a valid Texas driver’s
license or state ID card. If you do not possess a valid Texas driver
license or Texas identification card, you may submit a copy of a
utility bill in your name including a Texas address, or a Texas voter
To streamline your initial appointment, we ask that you print,
read, and complete each form within this packet prior to your
The forms and paperwork included are:
We would like to see your most current medical records from the last 12 months. You can ask your current primary care physician or specialist to fax or email us a copy of your records. Our fax number is 832-831-1882. You can print and complete our medical records form included within this packet and give it to your current doctor. Note that your doctor’s office may charge you to send us records.
If you are unable to complete or print this packet at home, you’ll need to fill out all of this information prior to being seen by the doctor. Please call us at 713-955-3325 or email us at info@TexasHerbalClinic.com if you have questions or issues.
Medical Cannabis Acknowledgement of Disclosure and Informed Consent
Please read each item below and initial in the space provided to indicate that you understand and agree with the information regarding the risks and side effects of using Medical Cannabis. Do not sign this agreement and do not use Medical Cannabis if you have questions about or do not understand the information you have received. Please tell us if you do not understand any of the information provided.
I am being evaluated for a physician's order for Medical Cannabis. The physician will make this order based, in part, on the medical information I have provided. I hereby acknowledge that I have not misrepresented my medical condition to obtain this recommendation and it is my intent to use Medical Cannabis only as needed for the treatment of my medical condition, not for recreational or non- medical purposes. I understand that it is my responsibility to be informed regarding state and federal laws regarding the possession, use, sale/purchase and/or distribution of Medical Cannabis. I have been informed of and understand the following:
Medical Cannabis Patient Agreement
Release of Liability
Your Qualifying Conditions for the “Texas Medical Cannabis Program”
to release and discuss any and all medical records and medical information that you have for me in your possession regarding my medical condition and my medical treatment, including but not limited to, my medical history, my medical treatment, your findings regarding my medical condition, records of consultations that I have had, records of medication prescribed for me, x-rays taken of me, my radiology reports, and hospital, and medical records to:
Texas Herbal Clinic
PHONE: (713) 955-3325
for the sole purpose of medical records review and certification of my medical condition.
I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse. I authorize the release or disclosure of this type of information.
This authorization is intended to be an unlimited, full, and complete Authorization for the release of any and all protected medical information as defined under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the Medical Records Access Act, as amended, and under the rules and regulations thereof, and covers all protected information from primary and secondary providers, health plans, health care clearinghouses, emergency services, financial and administrative transactions, and business associates. A covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign this authorization when the prohibition on conditioning of authorizations in 45 CFR 164.508(b) (4) applies. It is understood that the person to whom this Authorization is given has my permission to use and disseminate this information in his or her sole discretion.
1. Expiration. This authorization expires 18 months after patient signed this release.
2. Right to Revoke. I have the right to revoke this authorization by signing and dating a written statement revoking this authorization, and it shall become effective on delivery to you. If this authorization is revoked, any person or entity acting in good faith in reliance upon it and lacking actual knowledge of its revocation shall be held harmless.
3. Redisclosure. Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and is no longer protected by this rule.
4. Administrative Provisions. I revoke any prior authorizations I have made to disclose health information that are inconsistent with this authorization. This document shall be governed by Texas law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub L No 104-191, and the Medical Records Access Act, MCL 333.26261 et seq. However, I intend it to be honored in any jurisdiction where it is presented and for other jurisdictions to refer to Texas law and HIPAA to interpret and determine the validity and enforceability of this document. Photocopies or facsimile reproductions of this signed authorization shall be treated as original counterparts. I am providing this authorization voluntarily and have not been required to give it to obtain treatment. I am at least 18 years old and of sound mind.
5. Any Billing for Medical Records is solely the patient's responsibility
Cancellation/No Show Payment Policy
We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise when another patient fails to cancel and we were unable to schedule you for a visit, due to a full schedule.
It is our policy that all appointments must be cancelled at least 48 hours in advance of the appointment. If an appointment is not cancelled 48 hours in advance, you will be charged the full appointment cost. All patients will have the opportunity to show proof of an "urgent" reason as to why they were unable to make their scheduled appointment. Upon doing so, the patient will not be charged for the late cancellation.
Patients who "No Show" their visit will be charged for that visit and will be required to pay before being seen, again. All patients will have the opportunity to show proof of an "urgent'' reason as to why they were unable to make their scheduled appointment.
We understand that delays can happen, however, we must try to keep the other patients and doctors on time. We request you come 30 minutes early to your appointment to account for traffic and to complete the required paperwork. If you are 15 minutes past your scheduled time, your provider may not be able to complete a full visit or we will do our best to accommodate you and fit you into the schedule later in the day. If you cannot complete your visit you will be charged for the full visit and you will be required to book a new visit.
We will require that patients pay their account balances to zero (0) prior to receiving further services by our practice. We also require payment be rendered prior to services.
Acknowledgement of Receipt of Cancellation/No Show Policy