Patient Forms

Please select the appropriate packet to print and complete.

Patient Packet, Pregnant

Telehealth Informed Consent


Patient Packet, Non-pregnant

Telehealth Informed Consent


En Español

Por favor seleccione el paquete apropiado para imprimir y completar.

Paquete del Paciente

Consentimiento Informado por Telesalud


Medical Release Forms

New Patients to Tepeyac OB/GYN: Use this form to send your medical records to Tepeyac OB/GYN from another practice.

Current Patients with Tepeyac OB/GYN : Use this form to release your medical records from Tepeyac OB/GYN to another practice. Use this form to release your medical records from Tepeyac OB/GYN for your personal use. Please note: We are unable to accommodate medical records release requests via email, verbally over the phone, or by the patient portal. All submissions must be in writing with a signature using a Tepeyac form. Allow 7-10 business days for turnaround.

Other Forms and Services

Telehealth Informed Consent

Disability Forms:  If you are filing a disability claim, please send your forms to the office. Requests for disability forms have the following fees:

  • The charge for completing forms is $25.00 ($5.00 for each additional page after the initial page).
  • An additional $20.00 fee will be assessed for requests without a 24-hour notice.

A document replacement fee for lost prescriptions, forms, or letters will be assessed at $30.00 per item.

Privacy Notice

All new patients need to read the Privacy Notice, sign the Receipt, and return the receipt to the front desk at your initial visit. Established patients should review the Privacy Notice and sign an updated receipt annually or when the Notice is updated. You may sign the Privacy Notice electronically at Tepeyac’s Patient Portal when you register for secure messaging.

You may also be interested in optional forms mentioned in the Privacy Notice that you may obtain by clicking on the links below:

Divine Mercy Care may use limited patient information to contact you for fundraising purposes. You may opt-in/out of fundraising by completing this form.

You may request a list of disclosures made of your information, which were not for the purpose of your treatment, payment, or Tepeyac operations, and not otherwise made at your request. Please use this form to ask us to account for such disclosures.