Forms

New Patients Forms

Please complete the following forms AFTER you have scheduled your appointment:

Consent Form – English     /     Formulario de Consentimiento – Español

Intake Form – English     /    Formulario de Admisión – Español

Records Requests

• PDF Records Request Form
  • submitted via email, fax, or mail
  • may be used for any type of records request
• Online Records Request Form
  • submitted online
  • may only be used when records are to be sent to another provider
  • best completed on touch screen device (such as phone or tablet) as signature is captured electronically

For WIC Clinics

To refer a WIC client to the Lactation Foundation: WIC to LF Referral Form

If you need assistance, please call our office at 713-500-2800, option 1.