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New patients and patient updates:
NOTE: Please email, fax, or mail any of these forms to the following:
Email: fkay@libertymedsurg.com
Fax: 936.336.6517
Mailing address: 720 Travis St, Liberty, TX 77575
Adult Patient Form
Please fill out all pages. If faxing back to our office, please include the patient's current insurance card. For anyone under the age of 18, fill out the "Minor patient packet" and include a shot record.
Minor Patient Form
Please fill out all pages. If faxing back to our office, please include the patient's current insurance card. For anyone under the age of 18, fill out the "Minor patient packet" and include a shot record.
DOT Physical Exam Requirements
Please review this form and bring required documentation if you're seeking/ scheduled for a DOT physical exam.
Request Medical Records:
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Request Medical Records
Please make sure all of the fields in red are completely filled out. The second page is only necessary if you are requesting the records be released directly to the patient or patient's legal representative.
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