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Calvary Medical Clinic

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Patient Forms

Welcome Letter

Consent for Telemedicine Services

Adult Demographic Form

Child Demographic Form

Consent Form For Treatment of Child

HIPAA Notice of Privacy Practices

HIPAA Release Form

New Patient Medical History – Adult

New Patient Questionnaire – Child

No Show Policy

Notice of privacy practice -Spanish

Notice of Privacy Practice

Payment Policy

Practice General Policies

Sliding Fee Notice

Calvary Medical PA Sliding Fee Discount Program

Sliding Fee Discount Application

Medical Record Release Form

CONNECT WITH US

Cleveland Livingston Humble Humble UC Instagram

Livingston Clinic

Call Us: (936) 327-1055

Fax: (936) 329-8800

Visit Us: 309 Hwy 59 S Loop
Livingston, TX 77351

Humble Clinic

Call Us: (832) 995-5200

Fax: (832) 995-5201

Visit Us: 8484 Will Clayton Parkway
Humble, TX

Cleveland Clinic (Annex)

Call Us: (281) 592-9775

Fax: (281) 432-0548

Visit Us: 300 E Houston St
Cleveland, TX 77327

Cleveland Clinic (Main)

Call Us: (281) 592-9775

Fax: (281) 432-0548

Visit Us: 108 S William Barnett Ave.
Cleveland, TX 77327

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