Forms

Here are a list of forms available for your download. Your new patient packet contains a majority of the forms displayed on this page. If you are having problems please contact us.

Policies

Medical Records

To request records we must have a record release completed or a note stating patient name, date if birth and where records are to be sent, it must be signed and dated by the parent unless the patient is 18+ years old and they must sign.

The fee is $37.00 for the 1st 20 pages and $0.15 per page thereafter. You will be pre-billed before the records are sent out. Medical record requests are handled by PhotoStat once a week.

Form Completion

There is a fee of $25.00+ for form completion or letters.

Prescription Requests

All refill requests must be provided in writing either by mail, fax or by phone. If you have any questions please e-mail rxrequest@dallaspediatricneurology.com or call.

Design, Development & Hosting provided by 3 Service Solution.