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221 Regency Parkway Suit 105,
Mansfield Texas 76063
PH: 8008593119 FAX: 8665614066








Date of Birth :

Age :

Social Security Number :

Gender :

Marital Status :

Race or Ethnicity :

Home Address :

City :

State :

Zip Code :

Home Phone :

Cell Phone :

Employer :

Occupation :

Employer Address :


Emergency Contact :

Relationship to Patient :

Emergency Contact Home Number :

Emergency Contact Cell Phone Number :

I hereby authorize the Workforce Health System PLLC to render service or treatment as necessary. I understand payment for services is expected at the time of service. I authorize payment of benefits to the Workforce Health System PLLC for services rendered to myself.I understand that I am financially responsible for all charges whether or not paid by insurance and/or employer I also authorize the Workforce Health System PLLC or nsurance company to release any information required to process my claims.


I give the Workforce Health System PLLC consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations such as quality reviews.

I have been informed that I may review the Workforce Health System PLLC’s Notice of Privacy Practices for a more completed description of uses and disclosures before signing this consent.

I understand that the Workforce Health System PLLC has the right to change their privacy practices and that I may obtain any revised notices at the clinic, 16125 Cairnway Dr. Suite 106, Houston, TX 77084 or website:

I understand that I have to request a restriction of how my protected information is used. However, I also understand that the Workforce Health System PLLC is not required to agree to the request.If the Workforce Health System PLLC agrees to my requested restriction, they must follow the restriction(s)

I also understand that I may revoke this consent at any time, by making a request in writing, except for information already used or disclosed

A photocopy or fax of this consent is as valid as this original.

Signature :

Date :

Patient, Parent or Legal Guardian

If signed by patient representative, state relationship to patient :


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