Patient Info

Patient Information

Proudly Serving Arlington, TX, The Mid-Cities & The Metroplex

Thank you for choosing Arlington Family Practice, PA and trusting us with your healthcare needs. We are dedicated to providing quality care in a family-friendly environment and offer a full range of medical services for patients of all ages. Below you will find important patient information and documents.

If you have any questions prior to your appointment, please don’t hesitate to contact us. We look forward to working with you!

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Medical Services | Arlington Family Practice in Arlington, TX

Please complete the necessary forms below and bring them to your appointment. Plan to arrive 30 minutes prior to your scheduled time if you prefer to fill out the forms at our office. You may also fax your forms to (817) 548-7329. (If you do not arrive early to fill out your forms, your appointment will be rescheduled)

Remember to bring the following to your appointment:

  • All completed paperwork
  • Insurance information
  • Drivers license or picture ID

Dr. Rice and Dr. Gouldy are currently not accepting any new patients. At this time, we do not accept any new Medicare or Medicaid patients. In addition, our practice does not accept any minors as new patients unless they agree to be immunized and/or have already been immunized. All minors must be accompanied by a legal guardian at their very first office visit at Arlington Family Practice.

We accept cash, credit and debit as forms of payment. Your co-pay or any deductible is expected at the time of service. If you are self pay, full payment is expected. If copays are not paid at the time of the service, a $10 administrative fee will be added for billing. For further details, please read our Financial Policy Agreement below.

Please take a moment to read through our Notice of Privacy Practices and let us know if you have any questions. For more information, please visit our FAQ page.

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Our forms are in PDF format. Please click on the form to print and fill it out. The first three forms can be filled out online.


Health History

New Patient Consent Form

Financial Policy Form

Notice of Privacy Practices

Consent to Treat Minor

Fax Cover Sheet


Arlington Family Practice, PA complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.