PATIENT FORMS - fORMULARIOS PARA PACIENTES

The forms below are required of all patients seen at the Heidi Clinic. You may download and complete the forms prior to your visit or you may complete the forms on the day of your appointment. 

If you choose to complete your forms the day of the appointment, please plan to arrive at least

30 minutes prior to your appointment start time.


Los formularios a continuación son obligatorios para todos los pacientes atendidos en la Heidi Clinic. Puede descargar y completar los formularios antes de su visita o puede completar los formularios el día de su cita. Si elige completar sus formularios el día de la cita, planifique llegar al menos 30 minutos antes de la hora de inicio de su cita.


NOTICE OF PRIVACY PRACTICES - CLICK HERE

PATIENT CONSENT FORM - CLICK HERE


You need Adobe Acrobat Reader to download, complete, and print these forms. You may find Adobe Reader HERE free of charge

Necesita Adobe Acrobat Reader para descargar, completar e imprimir estos formularios. Si no tiene Adobe Reader, haga CLIC AQUÍ gratis

family planning program

These forms are available to female potential patients in the Family Planning Program. For your convenience, please download and complete the forms prior to your appointment. You may also complete them the day of your appointment.


  • INDIVIDUAL Eligibility Form in English CLICK HERE
  • HOUSEHOLD Eligibility Form in English CLICK HERE
  • HOUSEHOLD Eligibility Worksheet in English CLICK HERE                                          (must be used with Household Eligibility Form)


You need Adobe Acrobat Reader to download and complete these forms. It is free to you. CLICK HERE


Estos formularios están disponibles para pacientes potenciales masculinos y femeninos en el Programa de planificación familiar. Para su comodidad, descargue y complete los formularios antes de su cita. También puede completarlos el día de su cita.


El Formulario de elegibilidad INDIVIDUAL en espanol CLICK HERE

EL formulario de elegibilidad del HOGAR en espanol CLICK HERE


Necesita Adobe Acrobat Reader para descargar, completar e imprimir estos formularios. Si no tiene Adobe Reader, haga CLIC AQUÍ


HEALTHY TEXAS WOMEN

This program offers women's health and family planning services at no cost to eligible women in Texas. You may apply in many ways:


APPLY ONLINE HERE in English or Aquí en español


(Please keep in mind this online application works on desktop computers-not on mobile phones or tablets.)


APPLY BY PHONE

You may apply for Healthy Texas Women by calling 2-1-1. Representatives are available to take your call from 8 a.m. to 6 p.m. Central Time, Monday - Friday. 


MAIL OR FAX Your Application

You may download the form HERE or Aquí en español


Fill out the form then fax or mail it to:

Healthy Texas Women

P.O. Box 149021

Austin, TX 78714-9021

Fax (toll-free) 1-866-993-9971


APPLY IN PERSON

You may apply in person at one of our clinics. Please ensure you bring the items required for proof as you may receive services the same day. Examples of items needed for proof are HERE