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.
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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.
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Allergy & Asthma Patient Forms
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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)
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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)
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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)
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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)
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Gastroenterology Patient Form
Please bring the completed Gastroenterology Patient form with you to your appointment.
Gastroenterology Health History Form (English and Spanish)
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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)
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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
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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)
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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
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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)
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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)
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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
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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)
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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)
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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)