Patient Intake Form
Instructions
Only complete this form after you have contacted one of our clinics and have been scheduled for an appointment. You may download and print out our Patient Intake Form (PDF).
Kids Developmental Clinic does not discriminate against any person on the basis of race color religion national origin disability or age in admission treatment or participation in programs services and activities or in employment. Kids Developmental Clinic complies with the standards for privacy of patient information required by the Health Insurance Privacy and Accountability Act (HIPAA). For further information about our policies and standards please contact Diana P. Dinn at 713-668-6690.