New Patient Registration

The Patient Registration process and online form provides us with the information to set up your billing account with ARC. Information required includes demographics of each patient, responsible part for payment, and any health insurance information applicable to the patient.

In collecting demographic information, ARC adheres to the standards that were established by the U.S. Office of Management and Budget (OMB) in 1997. It is the same standard used by the U.S. Census Bureau. The OMB requires five minimum categories for data on race:

• American Indian or Alaska Native
• Asian
• Black or African American
• Native Hawaiian or Other Pacific Islander
• White

The OMB requires two minimum categories for data on ethnicity: 

• "Hispanic or Latino"
• "Not Hispanic or Latino”

A patient's response to the race and ethnicity questions are based on self-identification and the patient may choose more than one race.

MyChart® Registration & Caregiver Forms

Visit the MyChart® Registration & Caregiver Forms page for more information on how you can sign up for MyChart® and how to also gain access to your child or loved one's medical information. MyChart® is ARC's easy-to-use patient portal that allows quick and easy access anywhere and anytime.

Patient Information and Consent for Treatment of a Minor

Please fill out a Consent to Medical Treatment of a Minor form and have your child bring it to the appointment if you are the parent of a minor and would like your child to be seen by any of our providers without your presence.

Release of Information (ROI) Forms

Please visit the Release of Information (ROI) page for more information and to find the ROI form that best suits your needs.  Whether you are a new patient requesting a transfer of your medical records to Austin Regional Clinic or an established patient requesting your medical records from ARC, a Release of Information Form is required.

Health History Forms

Health History forms are for basic background health information. It will be reviewed by your doctor and nurse as soon as it is received, is confidential and part of your medical record.

For your convenience we provide our patient forms online. Please bring the completed form with you to your appointment. 

• Adult Health History

  Click here to print the Adult Health History form, complete it, and bring it to the office.

  The form can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

• Allergy & Asthma Patient Forms

  Please bring the completed Allergy-Asthma Patient form with you to your appointment.
  
  Allergy and Asthma Health History Form (English-Spanish)
  
  Allergy and Asthma New Patient Questionnaire

• Cardiology Patient Forms

  Please bring the completed Cardiology Patient form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Cardiology Health History Form(English and Spanish)

• Dermatology Patient Forms

  Please bring the completed Dermatology Patient form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Dermatology Health History Form (English and Spanish)

• Ear, Nose and Throat (ENT) Patient Forms

  Please bring the completed Ear, Nose and Throat (ENT) Patient Form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Ear, Nose & Throat (ENT) Adult Health History Form (English and Spanish)

  Ear, Nose & Throat (ENT) Pedi Health History Form (English and Spanish)

• Endocrinology Patient Forms

  Please bring the completed form with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Endocrinology/Fertility Health History Form (English and Spanish)

• Gastroenterology Patient Form

  Please bring the completed Gastroenterology Patient form with you to your appointment. 

  Gastroenterology Health History Form (English and Spanish)

• General Surgery Patient Form

  Please bring the completed General Surgery Patient form with you to your appointment. 

  General Surgery Health History Form (English and Spanish)

• Medicare Wellness Visit Forms

  Please fill out a patient history form for your annual Medicare Wellness Visit. Medicare requires a new form each year.   Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Medicare Wellness_Questionnaire_English-Spanish_Extensivist
  Medicare Wellness_Questionnaire_English-Spanish_FM-IM
  Medicare Wellness Checklist_English-Spanish

  This advanced directive form is designed to help you communicate your wishes about medical treatment at some time in the future when you are unable to make your wishes known because of illness or injury.

  Advance Directives form and information 
  Directiva a los médicos y a familiares o substitutos 

  Except to the extent you state otherwise, this document gives the person you name as your agent the authority to make any and all health care decisions for you in accordance with your wishes, including your religious and moral beliefs, when you are no longer capable of making them yourself.

  Medical Power of Attorney form and information 
  Declaración referente al poder médico

• Ob/Gyn Patient Form

  Please bring the completed Ob/Gyn Patient form with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Ob/Gyn Health History Form (English and Spanish)

• Orthopedic Patient Forms

  Please print and complete the appropriate form below, and bring to your consultation for your doctor and nurse to review. It will provide the basic background orthopedic health information that will be a confidential part of your medical record.

  Orthopedic Health History Form

  Established New Orthopedic Problem

  Post Op/Follow up Visit

  Follow up Visit - for Dr. Tipton Patients

  Sports Medicine Health History Form - for Drs. Zinn & Hairgrove Patients

• Pediatric Health History

  For your convenience we provide our patient forms online. Please use the forms below if you are a new patient to Austin Regional Clinic, and bring the completed form(s) with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Pedi Female 9-17 Health History (English and Spanish)
  Pedi Female Under 9yrs Health History (English and Spanish)
  Pedi Male 9-17 Health History (English and Spanish)
  Pedi Male Under 9yrs Health History (English and Spanish)

• Podiatry Patient Form

  Please bring the completed Podiatry Patient Form with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Podiatry Health History Form (English and Spanish)

• Preventive Care Form

  Austin Regional Clinic works hard to give the highest quality of care by providing yearly, physical examinations. Most insurance companies cover one wellness exam per year at no cost to the patient, including certain tests to detect disease in early stages or to prevent disease.

  Unfortunately, most insurance companies will not cover tests unrelated to the physical and can choose to not cover the full cost of the office visit for separate health concerns discussed during an exam.

  Please review the forms below to see examples of treatments or discussions that may not be covered in a physical examination.

  ARC Preventive Visit Charges Notice

  Cargos de Visitas Preventivas

  ARC Preventive vs. Acute Care FAQs

  Cuidado Preventivo vs. Cuidado Intensivo FAQs

• Rheumatology Form

  Please bring the completed Rheumatology Patient Form with you to your appointment. You can print the form below, fill it out, and bring it with you to your consultation.

  Rheumatology Health History Form (English and Spanish)

• Travel Medicine Form

  Please print the Travel Medicine Form below, fill it out, and bring it with you to your consultation.

  Travel Medicine Health History Form (English and Spanish)

• Weight Management Medicine Form

  Please bring the completed Weight Management Medicine Form with you to your appointment. Forms can be filled out in your browser via Adobe Reader or Acrobat, depending on browser type. Note that Adobe Reader cannot save typed data and we suggest printing copies for your records.

  Weight Management Health History Form (English and Spanish)