Jennifer C. Brooks, M.D., F.A.C.O.G.
Forms    
/Member/DrJenniferCBrooksMD/Images/ImageGallery/MEDICAL RECORDS RELEASE 2017.pdf
For your convenience we have attached forms needed for your first visit.  Please remember to bring these with you in order to expedite your appointment.  Copy and paste the form to your document to fill in via computer, or printout and fill in by hand, ( your handwritten signature is required for legality ). Thank you 
This form gives us detailed information on how you wish to be contacted.  If you DO NOT check the box, we CANNOT contact you in referenced manner.  If you check boxes for persons, other than yourself, to receive information, please supply their names. 
Release of Patient Information  

This form requires that you acknowledge HIPPA required patient privacy laws.   Please read the HIPPA REGULATIONS at www.hhs.gov/ocr/privacy
Acknowledgement Signature Sheet 

 Please fill out the PERSONAL HISTORY QUESTIONNAIRE to the best of your ability.  If you have any questions the nurse and Dr. Brooks will review this form with you at your visit.
Personal History Questionnaire  

For your convenience we have included this RECORDS RELEASE in order to receive your past medical records. 
Medical records release
Reach Us!   
 
 
1001 12th Avenue, Suite 150
Fort Worth, TX. 76104
Phone: (817) 334-0562
Fax: (817) 335-4328

Please call the office to schedule your appointment today

We look forward to serving you










 
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