Little Buddies Pediatric Clinic

Luis Lopez MD PA

FORMS

Little Buddies Pediatric Clinic values your time:

 In order to save you time in the waiting room, please click on the links below, print, and completely fill out all forms in advance, and bring them at the time of initial visit; otherwise, please come 15-20 minutes before appointment.

For new patients, please fill Patient Information, HIPAA Notice, Financial Policy, and TVFC-Elegibity Forms.

If you need Medical Records to be requested from your former provider, please fill the Release of Medical Information Form.

You can fax the forms, along with a copy of your Insurance Card, to 210.650.0926.

Thank you


English Forms

Patient Information.pdf

Financial Policy.pdf

HIPAA Notice of Privacy Rights.pdf

Vaccine Consent Form.pdf

TVFC Eligibility Screening Record.pdf

Release of Medical Information.pdf


Formas en Español

Información de Paciente.pdf

Notificación de Derechos de Privacidad.pdf

Política Financiera.pdf

Forma De Consentimiento De Vacuna.pdf

Encuesta de Elegibilidad Para el Programa de Vacunas de Niño - Inglés.pdf

Divulgación de Record Médico.pdf