New Patient Registration Form Page 2

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Tel: 713-936-2966
Srinivas R Panja MD
19701 Kingwood Dr. Building 4 Ste A
425 Holderrieth Street, Ste 108
920 Medical Plaza Dr Ste350
Kingwood TX 77339 fax: 281-319-4702
Tomball, TX 77375 fax: 832-698-2236
Woodlands TX77385 fax: 281-719-8671
Due to the new laws enacted by congress, we are required to have
signed this consent from prior to receiving treatment.
Do you consent to a medical examination and any procedures or tests deemed
necessary by Dr. Srinivas Panja while you are in our office?
YES
NO
Do you consent to the staff releasing information about appointments and or test results
to someone on your list?
YES
NO
Do you consent to the staff leaving messages on an answering machine or voice mail
system regarding appointments and or test results?
YES
NO
Do you consent to our office mailing you bills to your home?
YES
NO
Please list the names of the person or persons to whom we can discuss medical
information with:
NAME
RELATIONSHIP
SIGNATURE: ______________ Date: _________ Print Name: ___________________
If you wish this consent to be effective indefinitely or until you have revoked it please
initial here: _________________________.
If not initialed you will have to do a new form every time you visit.
You may revoke this consent at any time. By revoking consent you will receive no further
treatment from this office.
Greater Houston Diabetes & Endocrinology Center (GHDE)

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