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Wednesday, November 22nd, 2017

Forms

Whether you are first time parents of a newborn or just new to Dallas with a house full of kids, welcome to Clinical Pediatric Associates. Our mission is simple: to offer the highest level of medical expertise with the care and compassion that every child deserves. Please browse our website or schedule a visit to meet us.

To make your first visit more efficient please feel free to fill out the downloadable forms below.

New Patient Packet:

Other Forms:

  • Patient Portal Enrollment Form
  • Transfer of Medical Records Form
    Please note that we charge for records based on the reasonable fees designated by the Texas Medical Board: "Board rules define a reasonable fee for providing paper copies of medical records as no more than $25 for the first twenty pages and $.50 per page for every copy thereafter.  A reasonable fee for providing copies of medical records in electronic format is a charge of no more than: $25 for 500 pages or less and $50 for more than 500 pages.  Also, a reasonable fee of up to $15 may be charged for executing an affidavit, if requested".
    For more information, please visit: http://www.tmb.state.tx.us/page/general-council-faqs-for-consumers
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Telephone:
After Hours:
214-368-3659
214-368-3659 (Option 7)
8355 Walnut Hill Lane, Suites 105 & 205 Dallas, TX 75231
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