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Patient Forms

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These are examples of our Patient Forms for your reference only.

Our office will send all forms requiring signatures to your email, so that you can sign and complete using our AdobeSign software.

NEW PATIENT FORMS: For first time patients, we ask you to complete an electronic form. You will receive an email from our Adobe Sign account for Integrated Neurology (echosign@echosign.com), it provides a link for you to follow, fill out and sign the electronic form and hit SEND. Steps before your appointment:

  1. Complete New Patient Forms and submit before your appointment.

  2. Attach a copy of your Photo ID, Insurance card and COVID Vaccination Record in a New Message within Elation Passport. You may also Fax copies to 832-793-7540.

  3. Upload to Passport, or fax any lab results or imaging for Dr. Achari to review. 

FOLLOW UP PATIENT FORMS: For returning patients that have not seen Dr. Achari in over a year, we ask that you update all of your patient information. You will receive an email from our AdobeSign account for Integrated Neurology (echosign@echosign.com), it provides a link for you to follow, fill out and sign the electronic form and hit SEND.

VIRTUAL VISIT CONSENT FORM: We ask our patients to sign a form authorizing Dr. Achari to conduct their Office Visit in a virtual format such as FaceTime, Zoom or Skype to evaluate, test and diagnose them. 

RECORDS RELEASE AUTHORIZATION: This form authorizes Dr. Achari to share your medical records with another doctor, designated individual, company, agency, or facility.

MEDICARE/MEDICAID OPT-OUT CONSENT FORM: Dr. Achari does not accept Medicare or Medicaid. We ask our Medicare and Medicaid Self-Pay patients to sign this form acknowledging that they will not submit a claim for Dr. Achari's services.

BOTOX CONSENT FORM: Safety precautions during Botox treatment are very important during the Coronavirus pandemic. This form outlines safety measures required for Botox procedures. This must be completed, signed and sent to our office before your appointment date, along with a picture of your temperature on the morning of your appointment.

EEG CONSENT FORM: Safety precautions during EEG testing are very important during the Coronavirus pandemic. This form outlines safety measures required for EEG procedures. This must be completed, signed and sent to our office before your appointment date, along with a picture of your temperature on the morning of your appointment.