GTW Patient Information

Use our SECURE email communications between GTW and our patients to:

  • Complete patient forms in advance of your visit
  • Request prescription refills (please allow at least 5 business days for the refill)
  • Request routine follow-up appointments
  • Send messages about non-urgent medical or billing questions
  • Fees may apply for electronic communication related to medical services

Medical Records Request

These forms can be faxed to 972-733-6564, mailed or dropped off at our office.

  • Medical Records Request form to send or transfer your records to/from another provider such as a previous primary care physician, specialists, and mental health providers.
  • Medical Records to be Printed form to print medical records for your own files. Please note, a fee will be charged and must be paid prior to receipt of the printed medical records.
  •  Referral Request Form to request a referral (including medical records) for a specialist or mental health professional.

New Patient Forms

1)  Print and sign the New Patient Consent Forms (under 18 years old) or the New Patient Consent Forms (18 years old and up) 

2)  Print and complete the Comprehensive Screening Form - Female or Comprehensive Screening Form - Male  

3)  Print out and sign the Medical Records Request Form to send a copy of records from your current provider(s) to Girls to Women/Young Men's Health and Wellness. 

4)  These forms can be faxed to 972-733-6564 or bring them to your first appointment.

Annual Exam Form

1)  Print and complete the Comprehensive Screening Form - Female or Comprehensive Screening Form - Male  

2)  This form can be faxed to 972-733-6564 or bring it to your scheduled appointment.

Sports Physical Form

1)  Print and complete the Texas Pre-Participation Physical Evaluation form.  

2)  This form can be faxed to 972-733-6564 or bring it to your scheduled appointment.

Immunization Signature Sheet

Adult consent is required for immunizations. If your child is under 18 years of age and will be coming to an appointment by themselves, please print, sign and fax the Immunization Signature Sheet to 972-733-6564 prior to their appointment.

 

Notice of Privacy Practices

View or print the Notice of Privacy Practices.