Patient Name (required)

Date of Birth

Mailing Address

City/State/Zip

Home Phone

Work Phone

Cell Phone

 Male Female

 Married Single Divorced Widow

Your Email (required)

Insurance

Preferred Pharmacy Name and Address

Family Members also being seen in this practice. Name/Sex/Date of Birth

Emergency Contact Information (other than above)

Name

Relationship

Address

Phone

It is the policy of this office that all transactions be cash, check, money order, VISA or MasterCard at the time of services. We invite all our patients to discuss any questions regarding fees or services. I request and authorize the physicians and staff of South Austin Medical Clinic to care for my family and myself. I agree to having Physicians Assistants, Medical Assistants and/or Nurses assisting in patient care under the supervision of the doctor. I consent to blood testing for HIV or HBV, at no cost to the patient, if any clinic member is accidentally exposed to my blood.

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