Patient Forms

Pediatric Healthcare of Northwest Houston
If you would like to complete the New Patient Registration Forms before your child’s appointment, please click and print these forms. All forms must be completely filled out. Please make sure you bring the following to you New Patient Appointment.
  • Parent or Legal Guardian Photo ID
  • Immunization Records
  • List of Any Medications your Child is currently on
  • Insurance Card
  • Any Hospital Discharge Papers
  • Custody Papers if not the Biological Parent
  • Previous Pediatrician’s Name and Phone Number

New Patient Registration

Submit Online

All New Patients must be accompanied by a biological parent or legal guardian at their new patient appointment.

Click below buttons to download form

New Patient Registration

Consent To Texas Vaccine Registry (IMMTRAC)

Consent To Treat

Texas Vaccine For Children

NO Show Policy

Consent To Treat by Nurse Practitioner

Email Consent

Authorization for RX and School Excuse

Financial Policy

Request For Medical Records

If your child is scheduled for an appointment for ADHD, please download and complete the necessary ADHD forms:

ADHD Parent Initial Assessment

ADHD Teacher Initial Assessment

ADHD Parent Follow Up Assessment

ADHD Teacher Follow Up Assessment

Medical Records Request
If you are in need of a copy of your Child’s medical records, please allow us at least 48 hours to process. Please download the form and fax it to the clinic your Child has been seen at. It is important that this form is completely filled out.

Medical Records Request

Texas Vaccines For Children
Pediatric Healthcare of Northwest Houston, PA participates in the Texas Vaccines for Children Program. If you would like to see if your Child is elgible to receive free vaccines from the State of Texas, please complete this form at your Child’s Well Child Check-Up and our staff will inform you if your Child qualifies. If you want to learn more about this vaccine program, please click on the link below.

I want to learn more about Texas Vaccines for Children Program.

Texas Vaccine For Children

Vaccine Registry
As a participating provider of IMMTRAC, we request for Parents and/or Legal Guardians to consent for the Child’s Immunization to be registered with Texas Vaccine Registry also known as IMMTRAC at your first visit. If your Child is an established patient and you no longer wish to consent to IMMTRAC, please download the form below and complete it and send it to the address listed on the form. If your Child is a New Patient and you wish to learn more about IMMTRAC, please click on the link below.

I want to learn more about Texas Vaccine Registry, IMMTRAC.

Withdrawal of Consent To IMMTRAC Form

Consent To IMMTRAC Form

Covid vaccine now available