East Texas Orthopaedics And Sports Medicine

Steven C. Dickhaut, MD

 

Telephone

936-569-9443

 

Fax

936-560-5667

 

 

 

4800 NE Stallings Drive,

Suite 110,

Nacogdoches, TX  75965

Secure Forms

The forms listed below are to be completed online and will be retrieved by our staff prior to your scheduled appointment.  All information is confidential and is HIPPA compliant for secure data transfer and storage.  The 'Submit' button at the bottom of each form must be clicked for our office to receive the information. It is suggested that the forms be filled out in the order presented for ease of use.  After each successful form submission a submission confimation page will appear with instructions detailing how to continue filling out the remaining forms. 

 


 

Secure On-Line Forms

 

email icon link3Patient Information

Cicking the email icon to the left will access the Patient Information secure form page. Fill out the pages of the form and click on the "Submit" button at the bottom of the form to send the information to our office securely. All form sumissions made in this manner comply with HIPPA regulations for safegaurding patient information and are transmitted to our office via secure encryption methods.

 

 

email icon link3Medication Management Agreement

Cicking the email icon to the left will access the Patient Information secure form page. Fill out the pages of the form and click on the "Submit" button at the bottom of the form to send the information to our office securely. All form sumissions made in this manner comply with HIPPA regulations for safegaurding patient information and are transmitted to our office via secure encryption methods.

 

 

email icon link3Patient Permission to Release Information

Cicking the email icon to the left will access the Patient Information secure form page. Fill out the pages of the form and click on the "Submit" button at the bottom of the form to send the information to our office securely. All form sumissions made in this manner comply with HIPPA regulations for safegaurding patient information and are transmitted to our office via secure encryption methods

 

 

email icon link3New Patient Questionnaire

Cicking the email icon to the left will access the Patient Information secure form page. Fill out the pages of the form and click on the "Submit" button at the bottom of the form to send the information to our office securely. All form sumissions made in this manner comply with HIPPA regulations for safegaurding patient information and are transmitted to our office via secure encryption methods