Patient Forms
As a convenience to our patients, Tepeyac Family Center offers the following registration and update forms on-line. They are designed for you to print them, complete them, and bring them with you to your next appointment. This allows you to be prepared for your appointment when you arrive at the practice.
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If you are a new patient, please fill out:
New Patient Registration Form
Privacy Notice Form
HIPAA Release Form
Health History Questionnaire Form
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If you have an appointment for your annual examination, please complete:
New Patient Registration Form (if any updates are required)
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If you need to request your records from a previous doctor*:
Medical Release Form TO Tepeyac
*Please put your previous doctor's information in the blank spaces so that we may fax over the request.
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To request your records if you are leaving the practice:
Medical Release Form FROM Tepeyac
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If you are a current patient and have not updated your personal information since May 2005, please download:
Patient Registration Form
HIPAA Release Form
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If you are newly pregnant:
Health History Questionnaire Form
OB Family History and Genetic Screening Form
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If you have a change in address:
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If you are requesting the practice to complete disability claim forms, please complete your portion of the form and mail it to us:
Tepeyac Family Center
Attn: Nursing Staff
11135 Lee Highway
Fairfax, VA 22030
There will be a $25.00 charge for each use of this service payable prior to releasing the form to you.
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If you have a change in insurance:
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