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Forms

Patient Forms: English

  • Patient Registration Information
  • Patient Consent
  • Notice of Privacy Practices
  • Medical Information Release
  • Consent of Medical Treatment for Minors
  • Adult Past Medical History
  • Patient Portal Consent
  • Telemedicine Consent
  • Augmedix Consent
  • Cell Phone Policy
  • Medical Record Request From Another Facility
  • Medical Record Release To Another Facility
  • Immunization Registry Consent – Adult
  • Immunization Registry Consent – Minor
  • Dr. Olga Duchicela’s Health Risk Assessment
  • Dr. Jorge Duchicela and Mrs. Adamson’s Health Risk Assessment
  • Medicare Shared Savings Program, Our ACO

Formularios de Pacientes: Español

  • Informacion de Registro de Paciente
  • Consentimiento para el Tratamiento Medico
  • El Portal de Paciente
  • Consentimiento para Tratamiento Medico de Menores de Edad
  • Uso de Teléfonos Celulares y Dispositivos Móviles

Video Chat: Helpful Documents

  • How To Use Our Video Chat To See Your Physician
  • Troubleshooting Guide For Your Smartphone

Employment Application

  • Employment Application

All forms above are in Adobe PDF format, and require Acrobat Reader. If you do not have Acrobat Reader, you may download it for free by clicking below.

  • ©Copyright 2010 Youens and Duchicela Clinic
  • 402 Youens Drive
  • Weimar, Texas 78962
  • (979) 725-8545
  • (979) 725-8287