Clinic forms
Patient information forms.
Both new patients and patients who have seen Dr. Van Diest at a previous clinic should complete the demographics form prior to the first visit. You can submit this form online or download a copy to print and complete (links below).
Print patient information form
Online patient information form
Patients who have seen Dr. Van Diest previously should also complete the medication list form. You can submit this form online or download a copy to print and complete (links below).
Print medication list form
Online medication list form
Enrollment forms.
Please review and complete the membership agreement form before your first appointment. Both new patients and patients that have seen Dr. Van Diest at a previous clinic should complete this. You can complete and submit this form online or download a copy to print and complete (links below). The HIPAA Notice of Privacy Practices can be accessed via this link.
Print enrollment agreement form
Online enrollment agreement form
Medicare form.
Dr. Van Diest does not participate in Medicare at this time. All Medicare patients should review and complete this Advanced Beneficiary Notice (ABN) prior to the first visit. Both new patients and patients that have seen Dr. Van Diest at a previous clinic should complete this form if Medicare eligible. You can complete and submit this form online or download a copy to print and complete (links below).
Print Medicare ABN form.
Online Medicare ABN form.
New patient forms.
If you have not seen Dr. Van Diest previously, please select the appropriate form and complete before your appointment. You can submit this form online or download a copy to print and complete (links below).
Diabetic patient forms
Diabetic female new patient
Diabetic male new patient
Non-diabetic patient forms
Non-diabetic female new patient
Non-diabetic male new patient form
Medical records forms.
Even if you have seen Dr. Van Diest at a previous location, please complete the appropriate release of information (ROI) form(s) prior to your appointment if possible. You can complete and submit this form online or download a copy to print and complete (links below).
HCM Medical Group:
More information about requesting HCM Medical Group records online can be found here.
Hill Country Memorial (HCM) Hospital
Peterson Medical Associates (PMA):
Peterson Regional Medical Center (PRMC):
General release of information forms