Name *

First Name

Last Name

I understand I am being scheduled for a 15 minute intake exam to meet my provider, discuss screenings and preventative maintenance, go over my health history, and to be examined physically. I will NOT have all of my chronic illnesses addressed during this encounter. *

Agree

Disagree

I understand I can discuss TWO acute complaints during my intake (including refills) if I notify staff during scheduling. *

Agree

Disagree

I understand that appointment slots are limited and other patients will be affected by my tardiness or absence. *

Agree

Disagree

I will notify Austin Primary Care, LLC at least 24 hours prior to a non-emergent absence and I will arrive 15 minutes prior to my appointment time. *

Agree

Disagree

I understand arriving 15+ minutes late will count as an absence and I will have to reschedule my appointment. *

Agree

Disagree

I understand absences will incur a fee of up to $25 depending on my insurance. *

Agree

Disagree

I understand an absence from my intake appointment will cause immediate dismissal from Austin Primary Care, LLC *

Agree

Disagree

I understand 2 absences in a 12 month period will cause immediate dismissal from Austin Primary Care, LLC *

Agree

Disagree

I understand it is my responsibility to perform blood work 1 week prior to appointments and performing blood work after my appointment will require a subsequent visit to discuss. *

Agree

Disagree

I understand it is my responsibility to notify my provider of medication refill needs during my encounter and that there is no such thing as "automatic refills." *

Agree

Disagree

I agree to arrive in clean, well-kept clothing with shoes and socks, and to bath within 24 hours of my appointment with soap and water for the health and safety of others in the clinic. *

Agree

Disagree

I agree to notify staff if I have any infectious symptoms including fever, diarrhea, sore throat, thick mucous production, insect bites, bugs in my clothing, etc. *

Agree

Disagree

I understand it is my responsibility to schedule a follow up appointment within 7 days of any unplanned hospitalization or ER visits. *

Agree

Disagree

I understand that my doctor's office is not an appropriate outlet for my political views and I will not wear political attire to Austin Primary Care, LLC. *

Agree

Disagree