Patient Forms

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NEW AND ESTABLISHED PATIENTS NO SHOW/ LATE CANCELLATION POLICY:

In the event a patient no-shows for an appointment, AACM reserves the right to charge a $40.00 fee to the patient/responsible party. No-Show fees will not be used as a credit towards a future office visit and/or service.
Appointments must be cancelled at least 24 hours prior to the scheduled appointment time. If an appointment is cancelled with less than 24 hours’ notice, a $40.00 fee charge will be required to hold towards a future appointment. This amount can and will be used as a credit for the next office visit and/or service. If it is determined that you owe less than $40.00 at your next appointment and/or service, you will be issued a refund for the difference.
In the event a patient arrives late as defined by “late arrival” to their appointment, and cannot be seen by the provider on the same day, they will be rescheduled for another appointment time on a future date.
In the event a patient has incurred two (2) documented “no-shows” and/or “same-day cancellations,” the patient may be subject to dismissal from AACM. The patient’s chart is reviewed and dismissals are determined by AACM management, no exceptions, in accordance with AACM’s guidelines.

NEW PATIENT FORMS:

You will be sent our patient intake forms to your e-mail or mobile device on file before your appointment through our online check-in portal.

We do not accept Medicare – Medicare Eligible Patients must sign this Medicare Notice also.

MEDICAL RECORDS:

Download a printable PDF of our Medical Records Request

PRIVACY POLICIES:

Review our Privacy Policies

MINOR CONSENT:

If a minor is coming to an appointment or injection without a parent or legal guardian, please fill out a Authorization to Treat a Minor form before the appointment. Failure to present this form at the time of the appointment may cause us to cancel and reschedule the appointment to a different time. The adult bringing the minor must be 18 years or older and be able to show identification if asked.

SCHOOL FORMS:

Hello Parents!

AACM will receive school forms via fax- patient portal- and in person! Please make sure you submit a School Form Authorization 2025 with the school forms. You will also need to make sure all the parent information, medications requested and signatures are on the forms when submitted. *If this information is not on the form, it will delay the completion process.*

School forms require a $15.00 fee per school year, per family. This will cover all children, plus any changes we will need to make throughout the school year.

If you have any questions, please call 817-460-7447 to speak to a friendly member of our staff!

Preparing for Your First Visit

Please fill out the above patient and insurance information forms and bring them to your appointment, as this will save time. You can also fill out the forms when you get here–please arrive 15 minutes prior to your new patient appointment.

Please bring your asthma/allergy medications and any relevant medical records to your first appointment if possible.

Your doctor will evaluate you and make recommendations. A typical new patient visit can vary from 30 minutes to 1 hour. Thank you.

Patient Portal

Existing Patients — Access our Patient Portal